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Degenerative spondylolisthesis

95 citationsUpdated Oct 2026

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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 [31], surgical intervention is indicated for patients with intractable pain or neurologic symptoms [31]. Arthrodesis serves as an adjunct to decompression for spinal stenosis associated with degenerative or iatrogenic spondylolisthesis [10] and is also indicated in the treatment of progressive degenerative lumbar scoliosis [10]. Conversely, lumbar fusion has a poor success rate when used to treat back pain associated with multilevel disk degeneration [10]. Current surgical guidelines rely on radiographic assessment of the lumbosacral junction [26], though recent studies emphasize the importance of a global assessment of sagittal spinopelvic balance [26].

Surgical treatment provides significant long-term value to patients [6], with decompression and stabilization showing >80% success in appropriately selected patients with adult isthmic spondylolisthesis [31]. In the Medicare population, surgical treatment of stenosis with or without spondylolisthesis was associated with significantly lower mortality and total medical payments at 2 years compared with nonsurgical treatment [148], although residual confounding may have contributed to these findings [148]. Operative treatment offers significant benefit over nonoperative care in patients at least eighty years of age [2], and posterior decompression with instrumented fusion can be safe and effective in this demographic with proper patient selection [149]. Surgeons should anticipate favorable improvements in pain and functional ability in appropriately selected younger patients with symptomatic degenerative spondylolisthesis and stenosis [50].

No catastrophic progressions to neurologic deficit occurred as a result of watchful waiting for degenerative spondylolisthesis [6]. 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 [15]. Spinal stabilization and fusion constitute the most important parts of the procedure in spondylolisthesis [14]. Patients improving pelvic tilt after fusion achieved good clinical outcomes [7]. Reduction and maintenance of reduction in selected cases of severe spondylolisthesis is both desirable and obtainable [36].

Anatomy & Pathophysiology

Bony Anatomy & Variants

The spine comprises 7 cervical, 12 thoracic, and 5 lumbar vertebrae, along with 5 fused sacral and 4 or 5 fused coccygeal vertebrae [67]. Each vertebral body is a cylindrical mass of bone connected via pedicles to the posterior arch, which includes the lamina and spinous process [67]. Vertebral bodies primarily bear weight and transfer forces to the pelvis and hips, while posterior elements protect neural structures and function as a tension band [67]. Spondylolisthesis is defined as the forward slippage of one vertebra on its adjacent caudal segment [29]. Radiographic severity ranges from no anterior displacement to complete dislocation of L5 in front of the sacrum, termed spondyloptosis [29]. A decreased number of vertebrae is associated with degenerative spondylolisthesis, suggesting numerical variants may be a clinical problem [16]. Additionally, a unique neural arch shape in females and males with degenerative spondylolisthesis may clarify the condition's pathophysiology and explain its greater prevalence in females [12].

Functional Spinal Unit & Biomechanics

The functional spinal unit consists of two vertebrae, the intervening disk, and the facet joints with their capsules [71]. Vertebral bodies bear 70% to 90% of the static axial load of the spine [71]. Facet joints support 10% to 20% of axial load in a standing, neutral alignment [71]. 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 [71]. The lumbar spine possesses approximately 40° to 50° of lordosis [71]. Changes in sagittal balance that shift the center of gravity too far ventrally can result in significant pain and disability [71]. The preserved biomechanical behavior in the upper lumbar segments underscores the particular vulnerability of the lumbosacral junction to mechanical deficits [88]. Abnormal mechanical stress may contribute to intervertebral disc degeneration in old thoracolumbar fractures with kyphosis [101]. At the L4–5 and L5-S1 levels, facet tropism is associated with degenerative spondylolisthesis and lumbar disc herniation [34]. Facet orientation and facet tropism in the lower lumbar spine are significantly associated with degenerative lumbar spinal stenosis [120].

Disc & Ligamentous Pathophysiology

The intervertebral disk comprises an inner nucleus pulposus and an outer anulus fibrosus [72]. The nucleus pulposus serves as an osmotic pump to attract water and generate hydraulic pressure under significant loads [72]. The anulus fibrosus encapsulates the gelatinous nucleus pulposus, providing mechanical support to contain pressure and constrain intervertebral rotations [72]. The endplate is a bilayer of cartilage and bone that separates the disk from adjacent vertebrae and facilitates chemical transport for disk cellular vitality [72]. The intervertebral disk absorbs axial loads by deforming the nucleus pulposus to redistribute forces radially, which are resisted by the tensile properties of the anulus fibrosus [71]. Degeneration of the disc occurs with disc narrowing and subsequent ligamentous redundancy, which compromises the spinal canal area [81]. Instability resulting from disc degeneration may precipitate the formation of facet overgrowth and ligamentous hypertrophy [81]. The ligamentum flavum may be markedly thickened into the lateral recess where it attaches to the facet capsule, causing nerve root compression [81].

A popular hypothesis suggests that the spondylotic sequence begins with progressive disk desiccation, bulging, and collapse [141]. Low-grade segmental instability may result in facet joint subluxation and hypertrophy, as well as progressive thickening of the ligamentum flavum [141]. These anatomic changes contribute to gradual narrowing of the spinal canal and the eventual appearance of stenosis-related symptoms [141]. During lumbar extension, the ligamentum flavum buckles anteriorly and the posterior annulus bulges posteriorly, contributing to further reduction in the size of the central canal and lateral recesses [141]. Neuroforaminal narrowing occurs as the facet capsule is pushed anteriorly by the superior articular facet of the caudal vertebra during extension [141]. Degenerative changes in the functional spinal unit are multifactorial and can start in different anatomical structures [168]. Endplate changes such as fissuring and tears cause depletion of proteoglycan molecules in the cartilage endplate and microfractures and sclerosis in the bony endplate [168]. Degenerative bony endplate changes have been associated with reduced nutrient supply to the disc, a decline in proteoglycans and water content within the annulus fibrosus and nucleus pulposus, and subsequent disc degeneration [168].

Segmental Motion & Instability

In patients with L4 isthmic spondylolisthesis under weight-bearing conditions, displacement occurs between the anterior and posterior elements of L4, primarily in the form of separation during flexion [33]. Isthmic spondylolisthesis induces a geometric deformation of the lumbosacral hinge which modifies its anatomical relations with the iliocava junction [98]. Mild disc degeneration is implicated in the progression of bilateral L5 spondylolysis to spondylolisthesis [174]. Repetitive mechanical loading of the pars interarticularis may represent a key underlying mechanism for the development of isthmic spondylolisthesis [24].

Classification

Wiltse: This classification system is based on radiographic findings and age at onset, describing five types of spondylolisthesis [29]. Historically, spondylolisthesis cases have been divided into congenital and acquired types [29]. The Marchetti and Barozzi classification amplified the Wiltse classification [29].

Meyerding: Spondylolisthesis is graded on a scale from I to V according to the severity of the slip determined with plain radiographs [136]. The grade is determined by measuring the degree of slip using standing, neutral lateral radiographs of the lumbar spine [136]. The specific tiers are defined as follows: * Grade I: 0% to 25% slip [136]. * Grade II: 25% to 50% slip [136]. * Grade III: 50% to 75% slip [136]. * Grade IV: 75% to 100% slip [136]. * Grade V: greater than 100% slip [136].

Spinal Deformity Study Group: The Spinal Deformity Study Group Classification of Lumbosacral Spondylolisthesis exists as a classification system [161].

Other Considerations: No clinically applicable and validated classification of spinal stenosis has been published [130].

Clinical Presentation

Spondylolisthesis and spondylolysis occur more frequently in symptomatic patients than in asymptomatic individuals [1]. The prevalence of spondylolisthesis increases with age, participation in organized sports, and the presence of low back pain [24]. Repetitive mechanical loading of the pars interarticularis represents a key underlying mechanism for isthmic spondylolisthesis [24]. In adolescent spondylolisthesis, disc degeneration and instability are not concurrent; early disc degeneration observed on MRI is not always associated with abnormal mobility of the corresponding motion segment [25].

Imaging and Diagnostic Evaluation

Clinical history and physical examination aid in the diagnosis of degenerative lumbar spinal stenosis [42]. Imaging studies confirm the diagnosis, identify the levels involved, and detect associated pathology [42]. Plain radiographs: Standing AP and lateral views may demonstrate spondylolisthesis, disk space narrowing, end plate sclerosis, osteophytes, and facet hypertrophy [42]. Lateral and flexion-extension stress radiographs help determine whether spondylolisthesis is mobile and may reveal a slip not visible on the plain standing lateral view [42]. Magnetic Resonance Imaging: MRI best evaluates the degree of spinal stenosis by demonstrating 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 images may demonstrate loss of epidural fat at the exiting nerve root or frank nerve root deformation, suggesting entrapment in the foramina [42]. Computed Tomography: Radiographic findings indicating likely instability include gapped facets on axial CT scans and fluid-filled facets visible on axial T2-weighted MRI [42].

Pathophysiology and Instability Markers

No consensus exists regarding the definition of spinal stenosis in terms of spinal canal diameter or area measurements [42]. The degree of soft-tissue compression caused by ligament infolding is often underestimated when diameter or area measurements are used to assess 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]. A decreased number of vertebrae is associated with degenerative spondylolisthesis [16]. A unique neural arch shape may clarify the pathophysiology of degenerative spondylolisthesis and explain its greater prevalence in females [12]. Double-level lumbar spondylolysis and spondylolisthesis occur more often in women, with the most common site being L3–L5 [11].

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 [37]. The presence of dynamic spondylolisthesis and facet effusions suggests that decompression alone may result in a greater likelihood of failure [30].

Clinical Outcomes and Indications

Patients with intractable pain or neurologic symptoms may benefit from surgical decompression and stabilization for adult isthmic spondylolisthesis [31]. 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 [20].

Investigations

Plain radiography: Current surgical guidelines for spondylolisthesis rely on radiographic assessment of the lumbosacral junction, although recent studies emphasize the importance of a global assessment of sagittal spinopelvic balance [26]. Clinical outcomes in patients undergoing lumbar fusion for low-grade spondylolisthesis are not related to the radiographic reduction of the slipped vertebra [8].

MRI: Magnetic resonance imaging is the standard for advanced spinal imaging, superior to CT in most circumstances, particularly for identifying infections, tumors, and degenerative disc changes [87, 91]. MRI directly images neural structures and provides visualization of the nerve root within the foramen, a capability difficult to achieve even with postmyelography CT because contrast does not fully extend through the foramen [87, 91]. The combination of natural sitting and supine sagittal MRI is suitable for assessing translational instability in degenerative lumbar spondylolisthesis, comparable to traditional flexion-extension modalities [158].

MRI evidence of lumbar disc degeneration is present in 35% of patients aged 20 to 39 years and 100% of patients older than 50 [87]. However, magnetic resonance scan findings are not predictive of the development or duration of low-back pain [181]. MRI consistently underestimates the lumbar spinal canal cross-sectional area compared to CT, which may impact surgical planning and outcomes [179]. Modic changes, particularly Type 2, are common findings most frequently occurring at L4/L5 and L5/S1 levels [176]. A positive T2-weighted image showing a high-intensity zone (HIZ) indicates disc degeneration and may serve as a specific indicator for the physical diagnosis of discogenic low back pain [185].

Specific MRI features guide surgical decision-making. The presence of dynamic spondylolisthesis and facet effusions suggests that decompression alone carries a greater likelihood of failure, indicating that stabilization procedures should be considered [30]. A unique neural arch shape may clarify the pathophysiology of degenerative spondylolisthesis and explain its greater prevalence in females [12]. MRI features of facet joint degeneration and spinal stenosis do not show relevant correlation with reported pain relief after facet joint infiltration [184]. In riders, despite high prevalence of low back pain, there is no conclusive MRI evidence that the cause lies in undue disk degeneration, spondylolysis, spondylolisthesis, or paraspinal muscle pathologic changes [54].

Longitudinal MRI studies show that, other than more endplate changes in the surgery group, no differences in longitudinal change of MRI parameters are established between low back pain patients treated with or without fusion surgery [178]. Differences in L5-S1 disc contrast and homogeneity in texture analysis of T2-weighted images are observed in persons with and without low back pain [187]. Lumbar segmental instability is recognized at all levels, even in individuals appearing normal or having mild disc degeneration, when comparing MRI and plain radiographs [188]. MRI combined with paraspinal mapping or diffusion tensor imaging shows clear benefits in determining decompression levels for lumbar spinal stenosis compared to MRI plus neurological examination [182].

CT: Computed tomography allows for the identification of subtler fractures that might remain undiagnosed on plain radiographs and provides additional three-dimensional detail [89]. The primary disadvantage of CT compared to MRI is its inferior visualization of soft tissues [89]. Three-dimensional reconstruction can measure safe distances among critical bone markers, the intervertebral space, and nerve roots in patients with 1-degree degenerative lumbar spondylolisthesis and non-DLS [183].

Biomechanical and Motion Analysis: Weight-bearing conditions reveal displacement between the anterior and posterior elements of L4, primarily as separation during flexion, in patients with L4 isthmic spondylolisthesis [33]. In adolescent spondylolisthesis, disc degeneration and instability are not concurrent; early disc degeneration observed on MRI is not always associated with abnormal mobility of the corresponding motion segment [25].

Treatment

Non-Operative

Nonoperative management remains the initial standard of care, with successful pain relief achieved in approximately 80% of athletes with spondylolysis [151]. In cases of spondylolysis associated with osteopetrosis, the condition generally responds to non-operative measures such as the use of a lumbosacral corset or a thoracolumbosacral orthosis [55]. For chronic low back pain, non-operative treatment must be provided for at least 1 year before surgery is considered [167]. Additionally, non-surgical spinal decompression has been associated with a reduction in pain and an increase in disc height [164]. Long-term data indicate that watchful waiting for intervertebral disk herniation, degenerative spondylolisthesis, and lumbar spinal stenosis does not result in catastrophic progressions to neurologic deficit [6].

Operative

Indications: Surgical intervention is indicated for patients with intractable pain or neurologic symptoms from adult isthmic spondylolisthesis, where decompression and stabilization have shown >80% success in appropriately selected patients [31]. Operative management provides more effective relief than nonoperative treatment for degenerative lumbar stenosis in short-term follow-up data [32]. However, the evidence for spinal fusion or disc replacement in non-specific low back pain is poor; spinal fusion should only be performed as part of a randomised controlled trial, and lumbar disc replacement should not be performed [166]. Arthrodesis has a poor success rate when used to treat back pain associated with multilevel disk degeneration [10].

Surgical Approach / Technique: The standard surgical treatment for degenerative spondylolisthesis usually consists of posterior release associated with instrumented fusion [19]. An operation designed to stabilize the involved vertebra, relieve nerve-root irritation, and permit prompt mobilization provides a high percentage of good results for spondylolysis and spondylolisthesis [35]. For continuous double-level lumbar spondylolisthesis, transforaminal lumbar interbody fusion can effectively relieve symptoms, restore lumbar lordosis and sagittal spinal sequence, and improve quality of life [111]. In rare conditions such as traumatic spondylolisthesis combined with damage to the skin of the back, anterior fusion may be indicated where a posterior approach would be hazardous [116]. Direct surgical repair can yield high rates of pain relief in recalcitrant cases of spondylolysis in athletes [151].

Implant Selection: Both oblique lateral interbody fusion and transforaminal interbody fusion are effective surgical modalities for degenerative lumbar spondylolisthesis [129]. Standalone oblique lateral interbody fusion demonstrated better clinical outcomes at 1 week and 3 months than oblique lateral interbody fusion combined with percutaneous pedicle screw fixation in patients with spondylolisthesis [53]. Anterior lumbar interbody fusion for degenerative spondylolisthesis was associated with fewer perioperative complications and lower odds of nonroutine discharge than posterolateral fusion, though at substantially higher inpatient costs [39]. For spondylolysis-type lumbar spondylolisthesis complicated by osteoporosis, a bone cement-injectable cannulated pedicle screw is safe and effective [125].

Alignment / Balancing Strategy: Decompression alone is not inferior to decompression and fusion in patients with single-level lumbar spinal stenosis with spondylolisthesis [62]. 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]. A technique involving non-instrumented circumferential arthrodesis for high-grade L5-S1 spondylolisthesis with lumbosacral kyphosis results in a smaller reduction of the lumbosacral angle but reduces the rate of neurologic complications by at least a factor of three and leads to satisfactory functional outcomes compared to instrumented and intraoperative correction series [21].

Adjuncts: Non-contact orthopedic robot navigation for the treatment of lumbar spondylolisthesis was demonstrated to be a minimally invasive, precise, and stable surgical method [147].

Other Considerations: The general clinical efficacy of isobar hybrid dynamic stabilization with posterolateral fusion is equivalent to titanium rod fusion surgery for individuals with mild and moderate lumbar degenerative disease [112]. 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 [154].

Complications

Fusion and Pseudarthrosis: Spinal arthrodesis with pedicle screw-plate fixation achieves a 93 per cent fusion rate in patients with spondylolisthesis and a 90 per cent rate in those with painful degenerative disease [63]. In contrast, the fusion rate drops to 65 per cent in patients with preoperative pseudarthrosis treated with the same fixation method [63].

Neurologic Complications: Non-instrumented circumferential arthrodesis for high-grade L5-S1 spondylolisthesis with lumbosacral kyphosis reduces the rate of neurologic complications by at least a factor of three compared to instrumented and intraoperative correction series [21].

Revision Surgery: Lumbar diskectomy carries an early revision surgery rate for complications of 3.3% and a late revision rate for recurrent pathology of 11.6% at 4-year follow-up [58]. No differences were found in 90-day aggregated postoperative adverse events and 5-year lumbar revision surgery rates between noninstrumented and instrumented posterolateral approaches for lumbar degenerative spondylolisthesis [150].

Other Considerations: ALIF for degenerative spondylolisthesis is associated with fewer perioperative complications and lower odds of nonroutine discharge than PLF, though it incurs substantially higher inpatient costs [39]. At two years, patient satisfaction shows no significant difference between treatment groups for any outcome measures, regardless of preoperative spondylolisthesis presence [5]. Some patients undergoing microdecompression for lumbar synovial cysts develop late-onset low back pain and radicular pain, potentially necessitating additional surgery [56].

Recovery

Operative Outcomes and Durability: Short-term follow-up data indicate that operative management provides more effective relief than nonoperative treatment for lumbar spinal stenosis [32]. Treatment of spondylolysis and spondylolisthesis by an operation designed to stabilize the involved vertebra, to relieve nerve-root irritation, and to permit prompt mobilization of the patient after operation with support, provides a high percentage of good results [35]. The one-year postoperative radiological results and functional outcome of minimally invasive posterior lumbar fusion are satisfactory [146]. At mid-term follow-up, PLIF and OLIF provided sustained improvement in pain and function for lumbar spinal stenosis [144]. 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 [59]. The rate of fusion was 93 per cent in patients with spondylolisthesis treated with spinal arthrodesis and pedicle screw-plate fixation [63]. Beneficial effects of surgical intervention for lumbar synovial cysts persist long term, though some patients will develop late-onset low back pain, radicular pain, and may need additional surgery [56]. 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% [58]. Seven percent of lumbar disc patients had a residive lumbar disc operation within five years of their first operation [189].

Radiographic and Functional Correlates: 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 [162]. Pre-existing L5-S1 degeneration does not affect clinical and radiographical outcomes after isolated L4-5 fusion [38]. The clinical and radiographic efficacies of percutaneous spinal endoscopy for central lumbar spinal stenosis were good in short-term follow-up, and this surgery did not cause meaningful changes in IHI, CDS, and spine stability in short-term follow-up [57].

Prognostic Factors and Complications: Patients with lumbar spinal stenosis with long-term preoperative leg numbness have poorer outcomes at 2 years postoperatively [156]. 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 [190]. The timing between cauda equina syndrome diagnosis and decompression surgery did not significantly affect the long-term risk of conversion to fusion [191].

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)
• [L4] Patients improving pelvic tilt after fusion achieved good clinical outcomes in degenerative spondylolisthesis. [7] (10.1186/1471-2474-12-69)
• [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)
• [L3] This unique neural arch shape may clarify the pathophysiology of degenerative spondylolisthesis and explain its greater prevalence in females. [12] (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. [14] (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. [15] (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. [16] (10.1302/0301-620x.103b7.bjj-2020-1760.r1)
• [L1] This supports decompression alone as the preferred method of surgery for spinal stenosis, whether or not a degenerative spondylolisthesis is present preoperatively. [17] (10.1302/0301-620x.104b12.bjj-2022-0340.r1)
• [L5] Surgical treatment of degenerative spondylolisthesis usually consists in posterior release associated to instrumented fusion, though some cases can be more complex. [19] (10.1016/j.otsr.2016.06.022)
• [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. [20] (10.1097/corr.0000000000001252)
• [L4] This technique results in a smaller reduction of the lumbosacral angle but reduces the rate of neurologic complications by at least a factor of three and leads to satisfactory functional outcomes compared to instrumented and intraoperative correction series. [21] (10.1016/j.otsr.2021.103093)
• [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. [23] (10.2106/jbjs.22.00307)
• [L4] [24] (10.1177/23259671261466477)
• [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. [25] (10.1007/bf00390186)
• [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)
• [L5] Treatment of degenerative spondylolisthesis has evolved with numerous prospective randomized trials assessing fusion and instrumentation, and the use of bone morphogenetic proteins or soft-tissue stabilization devices. [27] (10.5435/00124635-200804000-00004)
• [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. [30] (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. [31] (10.5435/00124635-200910000-00003)
• [L5] Short-term follow-up data indicate that operative management provides more effective relief than nonoperative treatment, but prospective studies comparing the effects of nonoperative and operative interventions on the long-term natural history of lumbar spinal stenosis are needed. [32] (10.5435/00124635-199907000-00004)
• [L3] This study revealed the occurrence of displacement between the anterior and posterior elements of L4, primarily in the form of separation during flexion. [33] (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. [34] (10.1186/s12891-017-1849-x)
• [L4] Reduction and maintenance of reduction in selected cases of severe spondylolisthesis is both desirable and obtainable. [36] (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. [37] (10.1186/s12891-022-05017-1)
• [L3] Pre-existing L5-S1 degeneration does not affect clinical and radiographical outcomes after isolated L4-5 fusion. [38] (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. [39] (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)
• [L5] Surgeons should anticipate favorable improvements in pain and functional ability in appropriately selected younger patients with symptomatic degenerative spondylolisthesis and stenosis. [50] (10.1097/corr.0000000000001309)
• [L3] Standalone OLIF had better clinical outcomes at 1 week and 3 months than OLIF+PPSF in patients with spondylolisthesis. [53] (10.1186/s12891-020-3051-9)
• [L3] Although riders have a high prevalence of low back pain, there is no conclusive MRI evidence to suggest that the cause lies in undue disk degeneration, spondylolysis, spondylolisthesis, or pathologic changes of the paraspinal muscles of the lumbar spine. [54] (10.1177/0363546509336927)
• [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. [55] (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. [56] (10.1186/1749-799x-2-5)
• [L4] The clinical and radiographic efficacies of this surgery for central lumbar spinal stenosis were good in short-term follow-up, and this surgery did not cause meaningful changes in IHI, CDS, and spine stability in short-term follow-up. [57] (10.1186/s12891-021-04100-3)
• [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%. [58] (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. [59] (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. [62] (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. [63] (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. [88] (10.1186/s12891-025-09238-y)
• [L4] ISPL induces a geometric deformation of the lumbosacral hinge which modifies its anatomical relations with the ICJ. [98] (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. [101] (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. [111] (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. [112] (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. [116] (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. [120] (10.1155/2020/2453503)
• [L4] CICPS is safe and effective in the treatment of spondylolysis-type lumbar spondylolisthesis complicated by osteoporosis. [125] (10.1186/s12891-022-05904-7)
• [L1] Both OLIF and TLIF are effective surgical modalities in the treatment of degenerative lumbar spondylolisthesis. [129] (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. [130] (10.5435/jaaos-d-15-00034)
• [L3] [136] (10.1186/s13018-024-04647-6)
• [L5] [141] (10.5435/00124635-200704000-00003)
• [L3] At mid-term follow-up, PLIF and OLIF provided sustained improvement in pain and function. [144] (10.1186/s13018-026-06818-z)
• [L4] The one-year postoperative radiological results and functional outcome of minimally invasive posterior lumbar fusion are satisfactory. [146] (10.1016/j.otsr.2015.07.001)
• [L3] The non-contact orthopedic robot navigation for the treatment of lumbar spondylolisthesis was demonstrated to be minimally invasive, precise, and stable surgical method. [147] (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. [148] (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. [149] (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. [150] (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. [151] (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. [154] (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. [156] (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. [158] (10.1097/corr.0000000000001542)
• [L3] [161] (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. [162] (10.1186/s12891-021-04736-1)
• [L3] Non-surgical spinal decompression was associated with a reduction in pain and an increase in disc height. [164] (10.1186/1471-2474-11-155)
• [L5] The evidence for spinal fusion or disc replacement in non-specific low back pain is poor; spinal fusion should only be performed as part of a randomised controlled trial, and lumbar disc replacement should not be performed. [166] (10.1302/0301-620x.99b8.bjj-2017-0199.r1)
• [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. [167] (10.1016/j.otsr.2018.11.021)
• [L5] [168] (10.1002/jor.25240)
• [L5] [174] (10.1186/s12891-018-2011-0)
• [L4] Modic changes, particularly Type 2, are common radiological findings in lumbar spine imaging, most frequently occurring at L4/L5 and L5/S1 levels. [176] (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. [178] (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. [179] (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. [181] (10.2106/00004623-200109000-00002)
• [L2] MRI + (PM or DTI) showed clear benefits in determining decompression levels of lumbar spinal stenosis than MRI + NE. [182] (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. [183] (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. [184] (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. [185] (10.1186/s13018-023-04187-5)
• [L3] Differences were observed for L5-S1 disc contrast and homogeneity (p < 0.05). [187] (10.1002/jor.24930)
• [L3] Lumbar segmental instability was recognized at all levels even in individuals who appeared to be normal or to have mild disc degeneration. [188] (10.1007/bf00426175)
• [L3] Seven percent of the lumbar disc patients had a residive lumbar disc operation within five years of their first operation. [189] (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. [190] (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. [191] (10.5435/jaaosglobal-d-22-00153)

See Also

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

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