summary of guidelines for the treatment of lumbar spondylolisthesis

An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis †

• Academic Institute
• Department of Orthopedic Surgery
• Orthopedics & Sports Medicine
• Houston Methodist Hospital
• Houston Methodist
• Weill Cornell Medical College

Research output : Contribution to journal › Review article › peer-review

Background Context: The objective of the North American Spine Society (NASS) evidence-based clinical guideline on the diagnosis and treatment of degenerative lumbar spondylolisthesis is to provide evidence-based recommendations on key clinical questions concerning the diagnosis and treatment of degenerative lumbar spondylolisthesis. The guideline is intended to address these questions based on the highest quality clinical literature available on this subject as of January 2007. The goal of the guideline recommendations is to assist the practitioner in delivering optimum, efficacious treatment of and functional recovery from this common disorder. Purpose: To provide an evidence-based, educational tool to assist spine care providers in improving the quality and efficiency of care delivered to patients with degenerative lumbar spondylolisthesis. Study Design: Systematic review and evidence-based clinical guideline. Methods: This report is from the Degenerative Lumbar Spondylolisthesis Work Group of the NASS Evidence-Based Clinical Guideline Development Committee. The work group was comprised of multidisciplinary spine care specialists, all of whom were trained in the principles of evidence-based analysis. Each member participated in the development of a series of clinical questions to be addressed by the group. The final questions agreed on by the group are the subject of this report. A literature search addressing each question and using a specific search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology) and four additional, evidence-based, databases. The relevant literature was then independently rated by at least three reviewers using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final grades of recommendation for the answer to each clinical question were arrived at via face-to-face meetings among members of the work group using standardized grades of recommendation. When Level I-IV evidence was insufficient to support a recommendation to answer a specific clinical question, expert consensus was arrived at by the work group through the modified nominal group technique and is clearly identified as such in the guideline. Results: Nineteen clinical questions were formulated, addressing issues of prognosis, diagnosis, and treatment of degenerative lumbar spondylolisthesis. The answers to these 19 clinical questions are summarized in this document. The respective recommendations were graded by the strength of the supporting literature that was stratified by levels of evidence. Conclusions: A clinical guideline for degenerative lumbar spondylolisthesis has been created using the techniques of evidence-based medicine and using the best available evidence as a tool to aid practitioners involved with the care of this condition. The entire guideline document, including the evidentiary tables, suggestions for future research, and all references, is available electronically at the NASS Web site (www.spine.org) and will remain updated on a timely schedule.

• Degenerative lumbar spondylolisthesis definition
• Medical/interventional treatment
• Outcome measures
• Surgical treatment

ASJC Scopus subject areas

• Orthopedics and Sports Medicine
• Clinical Neurology

Access to Document

• 10.1016/j.spinee.2009.03.016

Other files and links

• Link to publication in Scopus

Fingerprint

• Spondylolisthesis Medicine & Life Sciences 100%
• Guidelines Medicine & Life Sciences 49%
• Spine Medicine & Life Sciences 44%
• Therapeutics Medicine & Life Sciences 12%
• Evidence-Based Medicine Medicine & Life Sciences 10%
• Consensus Medicine & Life Sciences 9%
• MEDLINE Medicine & Life Sciences 8%
• Quality of Health Care Medicine & Life Sciences 8%

T1 - An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis†

AU - Watters, III, William C.

AU - Bono, Christopher M.

AU - Gilbert, Thomas J.

AU - Kreiner, D. Scott

AU - Mazanec, Daniel J.

AU - Shaffer, William O.

AU - Baisden, Jamie

AU - Easa, John E.

AU - Fernand, Robert

AU - Ghiselli, Gary

AU - Heggeness, Michael H.

AU - Mendel, Richard C.

AU - O'Neill, Conor

AU - Reitman, Charles A.

AU - Resnick, Daniel K.

AU - Summers, Jeffrey T.

AU - Timmons, Reuben B.

AU - Toton, John F.

N1 - Funding Information: Author disclosures: WCW (consultant for Stryker; member of scientific advisory board at Intrinsic Therapeutics; receives remuneration from Blackstone Medical, Inc.); CMB (receives royalties from Life Spine; consultant for Depuy Spine and Medtronic Sofamor Danek; speaker for Depuy Spine and Stryker Spine; fellowship support from Depuy Spine; grant from Stryker Spine; member of board of directors at North American Spine Society; research support from Archus Orthopedics and Synthes Spine; receives financial support from Applied Spine); GG (receives royalties and consultant for Abbott Spine; stockholder at Allez Spine and DiFusion; speaker and travel support from Stryker Spine; member of scientific advisory board at DiFusion); MHH (royalties, stockholder, consultant, member of scientific advisory board at Relievant Medsystems; research support from Department of Defense); DSK (speaker and travel support from Smith & Nephew); CO (stockholder at Relievant and Nocimed; consultant for SpineView, ISTO, and Alleva; member of scientific advisory board at Relievant); DKR (consultant for medtronic); WOS (consultant for DePuy Spine; travel support from BrainLab; royalties from Depuy Spine).

PY - 2009/7

Y1 - 2009/7

N2 - Background Context: The objective of the North American Spine Society (NASS) evidence-based clinical guideline on the diagnosis and treatment of degenerative lumbar spondylolisthesis is to provide evidence-based recommendations on key clinical questions concerning the diagnosis and treatment of degenerative lumbar spondylolisthesis. The guideline is intended to address these questions based on the highest quality clinical literature available on this subject as of January 2007. The goal of the guideline recommendations is to assist the practitioner in delivering optimum, efficacious treatment of and functional recovery from this common disorder. Purpose: To provide an evidence-based, educational tool to assist spine care providers in improving the quality and efficiency of care delivered to patients with degenerative lumbar spondylolisthesis. Study Design: Systematic review and evidence-based clinical guideline. Methods: This report is from the Degenerative Lumbar Spondylolisthesis Work Group of the NASS Evidence-Based Clinical Guideline Development Committee. The work group was comprised of multidisciplinary spine care specialists, all of whom were trained in the principles of evidence-based analysis. Each member participated in the development of a series of clinical questions to be addressed by the group. The final questions agreed on by the group are the subject of this report. A literature search addressing each question and using a specific search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology) and four additional, evidence-based, databases. The relevant literature was then independently rated by at least three reviewers using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final grades of recommendation for the answer to each clinical question were arrived at via face-to-face meetings among members of the work group using standardized grades of recommendation. When Level I-IV evidence was insufficient to support a recommendation to answer a specific clinical question, expert consensus was arrived at by the work group through the modified nominal group technique and is clearly identified as such in the guideline. Results: Nineteen clinical questions were formulated, addressing issues of prognosis, diagnosis, and treatment of degenerative lumbar spondylolisthesis. The answers to these 19 clinical questions are summarized in this document. The respective recommendations were graded by the strength of the supporting literature that was stratified by levels of evidence. Conclusions: A clinical guideline for degenerative lumbar spondylolisthesis has been created using the techniques of evidence-based medicine and using the best available evidence as a tool to aid practitioners involved with the care of this condition. The entire guideline document, including the evidentiary tables, suggestions for future research, and all references, is available electronically at the NASS Web site (www.spine.org) and will remain updated on a timely schedule.

AB - Background Context: The objective of the North American Spine Society (NASS) evidence-based clinical guideline on the diagnosis and treatment of degenerative lumbar spondylolisthesis is to provide evidence-based recommendations on key clinical questions concerning the diagnosis and treatment of degenerative lumbar spondylolisthesis. The guideline is intended to address these questions based on the highest quality clinical literature available on this subject as of January 2007. The goal of the guideline recommendations is to assist the practitioner in delivering optimum, efficacious treatment of and functional recovery from this common disorder. Purpose: To provide an evidence-based, educational tool to assist spine care providers in improving the quality and efficiency of care delivered to patients with degenerative lumbar spondylolisthesis. Study Design: Systematic review and evidence-based clinical guideline. Methods: This report is from the Degenerative Lumbar Spondylolisthesis Work Group of the NASS Evidence-Based Clinical Guideline Development Committee. The work group was comprised of multidisciplinary spine care specialists, all of whom were trained in the principles of evidence-based analysis. Each member participated in the development of a series of clinical questions to be addressed by the group. The final questions agreed on by the group are the subject of this report. A literature search addressing each question and using a specific search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology) and four additional, evidence-based, databases. The relevant literature was then independently rated by at least three reviewers using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final grades of recommendation for the answer to each clinical question were arrived at via face-to-face meetings among members of the work group using standardized grades of recommendation. When Level I-IV evidence was insufficient to support a recommendation to answer a specific clinical question, expert consensus was arrived at by the work group through the modified nominal group technique and is clearly identified as such in the guideline. Results: Nineteen clinical questions were formulated, addressing issues of prognosis, diagnosis, and treatment of degenerative lumbar spondylolisthesis. The answers to these 19 clinical questions are summarized in this document. The respective recommendations were graded by the strength of the supporting literature that was stratified by levels of evidence. Conclusions: A clinical guideline for degenerative lumbar spondylolisthesis has been created using the techniques of evidence-based medicine and using the best available evidence as a tool to aid practitioners involved with the care of this condition. The entire guideline document, including the evidentiary tables, suggestions for future research, and all references, is available electronically at the NASS Web site (www.spine.org) and will remain updated on a timely schedule.

KW - Degenerative lumbar spondylolisthesis definition

KW - Diagnosis

KW - Imaging

KW - Medical/interventional treatment

KW - Outcome measures

KW - Surgical treatment

UR - http://www.scopus.com/inward/record.url?scp=67649677381&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=67649677381&partnerID=8YFLogxK

U2 - 10.1016/j.spinee.2009.03.016

DO - 10.1016/j.spinee.2009.03.016

M3 - Review article

C2 - 19447684

AN - SCOPUS:67649677381

SN - 1529-9430

JO - Spine Journal

JF - Spine Journal

Inclusion Criteria

Recommendation scope, diagnosis and imaging, medical/interventional treatment, surgical treatment, value/cost-effectiveness of spine care.

Diagnosis And Treatment Of Degenerative Lumbar Spondylolisthesis

Recommendations

• What is the role of pharmacological treatment in the management of degenerative lumbar spondylolisthesis?
• What is the role of physical therapy/exercise in the treatment of degenerative lumbar spondylolisthesis?
• What is the role of manipulation in the treatment of degenerative lumbar spondylolisthesis?
• What is the role of ancillary treatments such as bracing, traction, electrical stimulation and transcutaneous electrical stimulation (TENS) in the treatment of degenerative lumbar spondylolisthesis?
• What is the long-term result (four + years) of medical/interventional management of degenerative lumbar spondylolisthesis?

Recommendation Grading

Authoring organization.

North American Spine Society

Publication Month/Year

November 5, 2015

Last Updated Month/Year

July 31, 2023

Document Type

External publication status, country of publication.

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory, Emergency care, Hospital, Operating and recovery room, Outpatient

Intended Users

Physical therapist, chiropractor, nurse, nurse practitioner, physician, physician assistant

Assessment and screening, Diagnosis, Rehabilitation, Management, Treatment

Diseases/Conditions (MeSH)

D013168 - Spondylolisthesis

lumbar spondylolysthesis, Degenerative Lumbar Spondylolisthesis

Grading Table

• Help & FAQ

Guideline summary review: An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis

• Department of Physical Medicine and Rehabilitation
• Penn State Neuroscience Institute

Research output : Contribution to journal › Review article › peer-review

Background Context The North American Spine Society's (NASS) Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Degenerative Lumbar Spondylolisthesis features evidence-based recommendations for diagnosing and treating degenerative lumbar spondylolisthesis. The guideline updates the 2008 guideline on this topic and is intended to reflect contemporary treatment concepts for symptomatic degenerative lumbar spondylolisthesis as reflected in the highest quality clinical literature available on this subject as of May 2013. The NASS guideline on this topic is the only guideline on degenerative lumbar spondylolisthesis included in the Agency for Healthcare Research and Quality's National Guideline Clearinghouse (NGC). Purpose The purpose of this guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for patients with degenerative lumbar spondylolisthesis. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition. Study Design A systematic review of clinical studies relevant to degenerative spondylolisthesis was carried out. Methods This NASS spondyolisthesis guideline is the product of the Degenerative Lumbar Spondylolisthesis Work Group of NASS' Evidence-Based Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members used the NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guidelines were submitted to an internal peer review process and ultimately approved by the NASS Board of Directors. Upon publication, the Degenerative Lumbar Spondylolisthesis guideline was accepted into the NGC and will be updated approximately every 5 years. Results Twenty-seven clinical questions were addressed in this guideline update, including 15 clinical questions from the original guideline and 12 new clinical questions. The respective recommendations were graded by strength of the supporting literature, which was stratified by levels of evidence. Twenty-one new or updated recommendations or consensus statements were issued and 13 recommendations or consensus statements were maintained from the original guideline. Conclusions The clinical guideline was created using the techniques of evidence-based medicine and best available evidence to aid practitioners in the care of patients with degenerative lumbar spondylolisthesis. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flow chart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/Pages/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx and will remain updated on a timely schedule.

All Science Journal Classification (ASJC) codes

• Orthopedics and Sports Medicine
• Clinical Neurology

Access to Document

• 10.1016/j.spinee.2015.11.055

Other files and links

• Link to publication in Scopus
• Link to the citations in Scopus

Fingerprint

• Spondylolisthesis Medicine & Life Sciences 100%
• Guidelines Medicine & Life Sciences 49%
• Spine Medicine & Life Sciences 26%
• Therapeutics Medicine & Life Sciences 12%
• Consensus Medicine & Life Sciences 6%
• Webcasts Medicine & Life Sciences 5%
• Librarians Medicine & Life Sciences 5%
• Peer Review Medicine & Life Sciences 4%

T1 - Guideline summary review

T2 - An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis

AU - Matz, Paul G.

AU - Meagher, R. J.

AU - Lamer, Tim

AU - Tontz, William L.

AU - Annaswamy, Thiru M.

AU - Cassidy, R. Carter

AU - Cho, Charles H.

AU - Dougherty, Paul

AU - Easa, John E.

AU - Enix, Dennis E.

AU - Gunnoe, Bryan A.

AU - Jallo, Jack

AU - Julien, Terrence D.

AU - Maserati, Matthew B.

AU - Nucci, Robert C.

AU - O'Toole, John E.

AU - Rosolowski, Karie

AU - Sembrano, Jonathan N.

AU - Villavicencio, Alan T.

AU - Witt, Jens Peter

N1 - Publisher Copyright: © 2016 Elsevier Inc. All rights reserved.

PY - 2016/3/1

Y1 - 2016/3/1

N2 - Background Context The North American Spine Society's (NASS) Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Degenerative Lumbar Spondylolisthesis features evidence-based recommendations for diagnosing and treating degenerative lumbar spondylolisthesis. The guideline updates the 2008 guideline on this topic and is intended to reflect contemporary treatment concepts for symptomatic degenerative lumbar spondylolisthesis as reflected in the highest quality clinical literature available on this subject as of May 2013. The NASS guideline on this topic is the only guideline on degenerative lumbar spondylolisthesis included in the Agency for Healthcare Research and Quality's National Guideline Clearinghouse (NGC). Purpose The purpose of this guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for patients with degenerative lumbar spondylolisthesis. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition. Study Design A systematic review of clinical studies relevant to degenerative spondylolisthesis was carried out. Methods This NASS spondyolisthesis guideline is the product of the Degenerative Lumbar Spondylolisthesis Work Group of NASS' Evidence-Based Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members used the NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guidelines were submitted to an internal peer review process and ultimately approved by the NASS Board of Directors. Upon publication, the Degenerative Lumbar Spondylolisthesis guideline was accepted into the NGC and will be updated approximately every 5 years. Results Twenty-seven clinical questions were addressed in this guideline update, including 15 clinical questions from the original guideline and 12 new clinical questions. The respective recommendations were graded by strength of the supporting literature, which was stratified by levels of evidence. Twenty-one new or updated recommendations or consensus statements were issued and 13 recommendations or consensus statements were maintained from the original guideline. Conclusions The clinical guideline was created using the techniques of evidence-based medicine and best available evidence to aid practitioners in the care of patients with degenerative lumbar spondylolisthesis. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flow chart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/Pages/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx and will remain updated on a timely schedule.

AB - Background Context The North American Spine Society's (NASS) Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Degenerative Lumbar Spondylolisthesis features evidence-based recommendations for diagnosing and treating degenerative lumbar spondylolisthesis. The guideline updates the 2008 guideline on this topic and is intended to reflect contemporary treatment concepts for symptomatic degenerative lumbar spondylolisthesis as reflected in the highest quality clinical literature available on this subject as of May 2013. The NASS guideline on this topic is the only guideline on degenerative lumbar spondylolisthesis included in the Agency for Healthcare Research and Quality's National Guideline Clearinghouse (NGC). Purpose The purpose of this guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for patients with degenerative lumbar spondylolisthesis. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition. Study Design A systematic review of clinical studies relevant to degenerative spondylolisthesis was carried out. Methods This NASS spondyolisthesis guideline is the product of the Degenerative Lumbar Spondylolisthesis Work Group of NASS' Evidence-Based Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members used the NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guidelines were submitted to an internal peer review process and ultimately approved by the NASS Board of Directors. Upon publication, the Degenerative Lumbar Spondylolisthesis guideline was accepted into the NGC and will be updated approximately every 5 years. Results Twenty-seven clinical questions were addressed in this guideline update, including 15 clinical questions from the original guideline and 12 new clinical questions. The respective recommendations were graded by strength of the supporting literature, which was stratified by levels of evidence. Twenty-one new or updated recommendations or consensus statements were issued and 13 recommendations or consensus statements were maintained from the original guideline. Conclusions The clinical guideline was created using the techniques of evidence-based medicine and best available evidence to aid practitioners in the care of patients with degenerative lumbar spondylolisthesis. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flow chart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/Pages/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx and will remain updated on a timely schedule.

UR - http://www.scopus.com/inward/record.url?scp=84963565257&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84963565257&partnerID=8YFLogxK

U2 - 10.1016/j.spinee.2015.11.055

DO - 10.1016/j.spinee.2015.11.055

M3 - Review article

C2 - 26681351

AN - SCOPUS:84963565257

SN - 1529-9430

JO - Spine Journal

JF - Spine Journal

• Research article
• Open access
• Published: 01 April 2024

Biomechanical response of decompression alone in lower grade lumbar degenerative spondylolisthesis--A finite element analysis

• Renfeng Liu 1 ,
• Wei Tan 1 ,
• Zuyun Yan 1 &
• Youwen Deng 1  

Journal of Orthopaedic Surgery and Research volume  19 , Article number:  209 ( 2024 ) Cite this article

Metrics details

Previous studies have demonstrated the clinical efficacy of decompression alone in lower-grade spondylolisthesis. A higher rate of surgical revision and a lower rate of back pain relief was also observed. However, there is a lack of relevant biomechanical evidence after decompression alone for lower-grade spondylolisthesis.

Evaluating the biomechanical characteristics of total laminectomy, hemilaminectomy, and facetectomy for lower-grade spondylolisthesis by analyzing the range of motion (ROM), intradiscal pressure (IDP), annulus fibrosus stress (AFS), facet joints contact force (FJCF), and isthmus stress (IS).

Firstly, we utilized finite element tools to develop a normal lumbar model and subsequently constructed a spondylolisthesis model based on the normal model. We then performed total laminectomy, hemilaminectomy, and one-third facetectomy in the normal model and spondylolisthesis model, respectively. Finally, we analyzed parameters, such as ROM, IDP, AFS, FJCF, and IS, for all the models under the same concentrate force and moment.

The intact spondylolisthesis model showed a significant increase in the relative parameters, including ROM, AFS, FJCF, and IS, compared to the intact normal lumbar model. Hemilaminectomy and one-third facetectomy in both spondylolisthesis and normal lumbar models did not result in an obvious change in ROM, IDP, AFS, FJCF, and IS compared to the pre-operative state. Moreover, there was no significant difference in the degree of parameter changes between the spondylolisthesis and normal lumbar models after undergoing the same surgical procedures. However, total laminectomy significantly increased ROM, AFS, and IS and decreased the FJCF in both normal lumbar models and spondylolisthesis models.

Hemilaminectomy and one-third facetectomy did not have a significant impact on the segment stability of lower-grade spondylolisthesis; however, patients with LDS undergoing hemilaminectomy and one-third facetectomy may experience higher isthmus stress on the surgical side during rotation. In addition, total laminectomy changes the biomechanics in both normal lumbar models and spondylolisthesis models.

Introduction

Lumbar degenerative spondylolisthesis (LDS) is a common disorder of the spine, frequently observed in the elderly, which manifests as the upper vertebrae slipping relative to the lower vertebrae on the basis of images [ 1 , 2 ]. The L3-4 and L4-5 segments are the most affected index segment [ 3 ]. In clinical scenarios, most of the patients suffer from lower back pain due to LDS; with the progress in slip, the condition is accompanied by pain and numbness in the lower limbs, leading to functional limitations [ 4 ]. Around 4.1% of individuals suffer from LDS globally [ 5 ], which lays a huge economic burden [ 6 ]. Surgical intervention is the traditional method used for patients who are not responding to conservative treatment options [ 6 , 7 ].

Decompression combined with fusion, whether through open approaches or minimally invasive surgeries, has achieved excellent clinical results in patients with spondylolisthesis [ 8 , 9 ]. Laminectomy combined with cage implantation assisted with screw-rod fixation can effectively release the pressure of the nerve root or dura well and also avoid the risk of iatrogenic instability [ 10 ]. However, concerns have been raised regarding the necessity of instrument fusion which can lead to additional costs, longer surgical time, more blood loss, and possible nerve root injury [ 11 , 12 ]. Several studies have compared decompression alone with decompression united fusion and have shown that decompression alone can yield excellent clinical outcomes [ 1 , 6 , 12 , 13 ]. However, some researchers believe certain patients with lower-grade LDS could benefit more from laminectomy combined with fusion, based on their studies [ 1 ]. The choice between the two procedures may depend on the patient’s symptoms and the segment stability, as decompression alone may not be suitable for mechanical back pain or unstable spondylolisthesis [ 3 , 10 ]. Currently, there is contradictory evidence regarding the indications and clinical outcomes of the two surgeries based on published reports [ 12 , 14 ]. In most cases, the choice between decompression alone or instrument fusion in treating LDS depends on the surgeon’s preference, as there is still insufficient evidence to evaluate which operative type is more effective [ 5 ]. While clinical studies comparing decompression alone with additional instrument fusion are common, there are very few studies comparing the biomechanics of the two surgeries.

The finite element method (FEM) is a powerful tool in the field of biomechanics and has been used to study spine biomechanics in the last decades [ 15 ]. FEM has several advantages when compared to in vitro experiments, including good repeatability and low cost. Additionally, it is easy for FEM to obtain the stress or pressure distribution of bone and soft tissue [ 15 ]. At present, the common biomechanical parameters include segmental ROM, IDP, AFS, FJCF, and IS. In this FE study, we evaluated the biomechanical characteristics of lower LDS after total laminectomy, hemi-laminectomy, and one-third facetectomy by analyzing the above parameters.

Intact L3-S1 finite element model

The L3-S1 finite element (FE) model was established based on high-resolution computed tomography images of a 27-year-old healthy male participant (height :175 cm, weight :70 kg). The L3-S1 geometric model was first constructed based on the lumbar CT data using the software Mimics 21.0 (Materialise Inc., Leuven, Belgium), Geomagic Wrap 2017 (Geomagic, Inc., Research Triangle Park, NC, United States), and SOLIDWORKS 2018 (Dassault Systèmes Inc., France). The intact FE model was then established by meshing the geometric model, checking the mesh quality, and FE preprocessing in the software of HyperMesh 2020 (Altair Engineering, Inc., Executive Park, CA, United States). The normally intact L3-S1 model is shown in Figs.  1 and 2 , and the lumbar spondylolisthesis model is shown in Fig.  1 .

The normally intact L3-S1 model and lumbar spondylolisthesis model

Details of the normally intact L3-S1 model

The intact L3-S1 FE model included cortical bone, cancellous bone, cartilage, endplate, annulus fibrosus, nucleus pulposus, and seven major ligaments, namely, the anterior longitudinal (ALL), posterior longitudinal (PLL), ligament flavum (LF), supraspinous (SSL), interspinous (ISL), capsular (CL), and intertransverse ligaments (IL). The thickness of the endplate and cortical bone was set to 0.6 mm, and the cartilage material is elastic, with a joint gap of 0.5 mm. The major ligaments were assumed to be tension-only truss elements. The volume of the nucleus pulposus accounted for 40% of intervertebral disc [ 16 ]. The posterior cartilage was modeled as surface-to-surface friction contact with a friction coefficient of 0.1 [ 17 ]. A detailed description of the mechanical properties, the element type, and numbers is listed in Table  1 .

Surgical FE models and spondylolisthesis model

Seven experiment models were constructed by modifying the intact FE model (model A). For the intact spondylolisthesis model (model B), L4 vertebrae slipped 5 mm to simulate grade I spondylolisthesis based on the Meyerding classification. The slipping part accounts for 1/7 of the length of the L5. To ensure the consistency of L4 vertebrae anteroposterior diameter, bilateral isthmuses were stretched in the spondylolisthesis models. In models A and B, a hemilaminectomy and total laminectomy were performed, respectively, at the L45 segment. In the hemilaminectomy models, the left side LF was removed; in the total laminectomy models, all the LF, SSL, and ISL were removed. The hemilaminectomy models were divided into models A1 and B1, and total laminectomy models were divided into models A2 and B2. For the 1/3 facetectomy, we only removed part of cartilage and CL, and didn’t remove any bony structure. The 1/3 facetectomy models were divided into models A3 and B3. All the modified models are shown in Fig.  3 .

A , the intact spondylolisthesis model (Model B); B , the model of hemi-laminectomy; C , the model of total laminectomy; D , one-third facetectomy

Boundary and loading conditions

To simulated different types of movement, the normal mode wasl subjected to a 10 Nm applied to the L3 cranial endplate for flexion (FLE), extension (EXT), left lateral bending (LLB), right lateral bending (RLB), left axial rotation (LAR), and right axial rotation (RAR) movement. A vertical compression load of 400 N was applied to the central area of the L3 cranial endplate and kept vertical at all times [ 21 ]. During lumbar movement, the sacrum was fixed in all directions. The displacement of the intact model at 10 Nm was calculated, and the calculated displacement load was applied to the surgical models instead of the moment. All surgical models were analyzed using Abaqus 2020(Abaqus, Inc., Providence, RI, United States).

The loading condition for validation was the same as in previous studies (10 Nm pure moment). The ROM of each segment is illustrated in Fig.  4 , and the predicted value of ROM was found to be consistent with previous results [ 22 , 23 , 24 , 25 , 26 ].

Comparison of ROM between the current models with previous studies. LLB, left lateral bending; RLB, right lateral bending; LAR, left axial rotation; RAR, right axial rotation

The A-C in Fig.  5 shows the different models of ROMs in the L4-L5 segments. The results indicated that hemilaminectomy and facetectomy had a relatively minor impact on segment stability, regardless of whether normal or spondylolisthesis models were used. In contrast, total laminectomy had a significant impact on stability. Additionally, for the same surgical condition, the movement level of spondylolisthesis models was slightly greater than that of normal lumbar models.

Comparison of ROM、IDP and AFS at the L4-L5 segment of different models. A-C indicates ROM, D-F indicates IDP, and G-L indicates AFS. The model A (intact normal model); the model A1 (hemi-laminectomy); the model A2 (total laminectomy); the model A3 (one-third laminectomy); The model B (intact spondylolisthesis model); the model B1 (hemi-laminectomy); the model B2 (total laminectomy); the model B3 (one-third laminectomy); FLE, flexion; EXT, extension

Compared to the intact normal model (model A), the ROM of the intact spondylolisthesis model (model B) increased by 21.69% (1.45°), 26.1% (1.67°), and 24.37% (0.53°) during flexion-extension, lateral bending, and rotation, respectively. In the lumbar normal models, the maximal motion of models A1 and A3 occurred during extension movement, with increasing rates of 3.71% and 4.17%, respectively. Compared to model A, the ROM of model A2 increased by 15.74%, 3.69%, 5.84%, 5.73%, 9.23%, and 9.37% during FLE, EXT, LLB, RLB, LAR, and RAR, respectively. Similarly, in the spondylolisthesis models, the maximal motion of models B1 and B3 occurred during extension movement, with the increase rates being 3.81% and 4.10%, respectively. Compared to model B, the ROM of model B2 increased by 19.2%, 3.68%,6.82%, 7.67%, 11.9%, and 10.58% during FLE, EXT, LLB, RLB, LAR, and RAR, respectively.

The IDP changes in L4-L5 segments of normal lumbar spine model and lumbar spondylolisthesis model are shown in D-F of Fig.  5 . According to the calculated results, no significant increase was observed in IDP after three decompression-alone procedures in all the models lateral bending and axial rotation. For models A1, model A3, model B1, and model B3, their maximal rate occurred in extension movement, the increase rates being 1.26%, 1.34%, 2.76%, and 2.79%, compared with models A and B, respectively. After total laminectomy, the IDP of model A2 increased by 11.44%, 1.49%, 1.11%, 1.23%, 2.53%, and 2.51% compared to model A during FLE, EXT, LLB, RLB, LAR, and RAR, respectively; while the IDP of model B2 increased by 20.98%, 3.83%, 4.56%, 3.41%, 8.09%, and 6.46% compared with model B during FLE, EXT, LLB, RLB, LAR, and RAR, respectively. However, there was a significant decrease in the tendency of the segmental IDP after the vertebrae slipped. The IDP of the model B decreased by 34.58%, 5.1%, 32.92%, 32.95%, 40.58%, and 32.35% during FLE, EXT, LLB, RLB, LAR, and RAR, respectively.

Annulus fibrosus stress

Compared with normal lumbar models, the annulus fibrosus stress (AFS) in the spondylolisthesis models presented a higher value for the same conditions. The AFS of model B increased by 25.02%, 31.54%, 14.64%, 8.11%, 13.60%, and 7.01% under FLE, EXT, LLB, RLB, LAR, and RAR, respectively, when compared to model A. In the normal lumbar models, the AFS of model A2 increased by 19.12% more than model A under flexion, with other motions having little influence on AFS. In the spondylolisthesis models, the AFS of model B2 increased by 17.14%, 5.5%, 2.75%, and 5.46% compared with model B under FLE, EXT, lateral bending, and axial rotation, respectively. The AFS comparison of different models at the L4-L5 segment is shown in G-L of Fig.  5 , while the stress distribution of the disc at the L4-L5 segment is shown in Fig.  6 .

The stress is primarily distributed in the posterior-lateral region of the caudal intervertebral disc during flexion movement, and the stress is primarily distributed in the right anterior or left anterior region of the caudal intervertebral disc during axial rotation movement, while the stress is primarily distributed in the right posterior or left posterior region of the cephalic intervertebral disc during lateral bending movement

Facet joints contact force

The comparison of facet joint contact forces of different models in segments L4-5 is shown in A-C of Fig.  7 . The greatest facet joint contact force was observed during the axial rotation in all movements, followed by extension, and the FJCF of axial movement was above 200 N. For both normal lumbar and spondylolisthesis models, FJCF decreased after each of the decompression-alone procedures, with a more significant decrease observed with resection ranges. Except for rotation movement, the contact force of bilateral facet joints in model B showed an increase compared to model A; the value of FJCF in spondylolisthesis models was larger than that in normal lumbar models for the same surgical operation. In the normal lumbar models, the greatest decrease in FJCF occurred in total laminectomy, followed by facetectomy and hemilaminectomy; the same tendency also occurred in spondylolisthesis models. In addition, the greatest decrease degree of the FJCF occurred during extension (more than 20%), followed by lateral bending and rotation after the three surgeries in all surgical models. The decrease in FJCF after the same surgery was not significant between normal and spondylolisthesis models.

Figure A-C shows the FJCF, the “-L” presents the left facet joint, and “-R” presents the right facet joint. Figure D-F shows the IS, the “-L” presents the left isthmus, and “-R” presents the right isthmus

Isthmus stress

The isthmus stress (IS) of different models at the L4-L5 segment is shown as D-F in Fig.  7 . The results showed that the maximal stress occurred in rotational movement in all models, followed by extension, lateral bending, and flexion movements. There was an apparent increase in stress on the ipsilateral isthmus during lateral bending, while contralateral isthmus stress had a larger change under axial rotation.

Compared to model A, the IS of model B increased at different levels, especially during flexion and extension movements, with average rates of 71.22% and 22.85%, respectively. For the hemilaminectomy, the stress of the resection side had an increase of more than 50% during extension and lateral bending in models A1 and B1, and the increasing rates were more than 110% during rotation. For the total laminectomy, the stress of the bilateral isthmus showed a huge increase in models A2 and B2 under all movements. Although the IS of spondylolisthesis models showed a larger value than normal lumbar models after hemilaminectomy and total laminectomy, there was no greater extent of increase to observe. The stress contour map of hemilaminectomy and total laminectomy under rotation is shown in Fig.  8 .

The stress distribution of isthmus during axial rotation. LAR, left axial rotation; RAR, right axial rotation

In recent years, studies have shown that laminectomy alone also yields satisfactory clinical outcomes for LDS [ 12 , 27 ], and some studies have reported that a higher rate of reoperation for laminectomy alone compared to laminectomy combined with instrument fusion in the postoperative [ 28 ]. However, there is a lack of biomechanical results of laminectomy alone for LDS. In this study, we developed a normal L3-S1 finite element model based on CT data and then constructed a lower-grade LDS model and several surgical models using simulation tools. The purpose of this study was to investigate the biomechanical characteristics of decompression alone for spondylolisthesis using parameters such as ROM, IDP, FJCF and IS calculated by FE software.

The range of motion

Laminectomy is a common surgical method for lumbar stenosis. According to the results of finite element analysis and cadaveric specimen experiments [ 29 , 30 ], unilateral laminectomy had a minimal impact on the segmental ROM. Zander et al. conducted finite element analysis by establishing a lumbar spine model to compare the biomechanical effects of graded facetectomy. They found that if facetectomy is performed in a graded manner, removing less than 50% of the bone, lumbar spine stability will not be significantly affected [ 21 ]. In the Burkhard et al. study, the segmental ROM after hemilaminectomy increased by 6% (5–10%), 3% (1–5%), and 12% (4–22%) during flexion-extension, lateral bending and rotation, respectively [ 31 ]. These studies collectively indicate that hemilaminectomy and facetectomy involving less than 50% of the facet joints have no apparent adverse effects on spinal stability, consistent with our findings. In our study, hemilaminectomy increased 3.18%, 1.15%, and 3.71% in flexion-extension, lateral bending, and axial rotation ROM, respectively. Hemilaminectomy and 1/3 facetectomy led to increases of 3.58%, 1.28%, and 4.17% in the mentioned ROM parameters. In addition, the ROM of the intact lower-grade spondylolisthesis model (model B) showed an obvious increase compared to model A, but hemilaminectomy or 1/3 facetectomy did not significantly change the ROM in the spondylolisthesis model. Considering that the anterior vertebral body bears a considerable portion of spinal stress, the buffering effect of intact intervertebral discs and the preservation of posterior midline structures such as facet joints and spinous processes compensate for removing partial bone structures and ligaments, we speculate that even with partial removal of bone structures and ligaments, spinal stability may not be significantly altered.

However, the index segment bears the risk of iatrogenic instability after total laminectomy if it lacks an additional fusion procedure. Postacchini et al. reported that 3 out of 32 patients suffered from significant segment disability after total laminectomy [ 32 ]. In Lener et al.‘s study [ 30 ], when complete laminectomy was performed with bilateral partial facetectomy, segmental ROM increased by 20% ± 15.9, 11% ± 9.9, and 19% ± 10.5% in flexion-extension, lateral bending, and axial rotation, respectively. In our study, due to the preservation of facet joints, the percentage increase in segmental ROM was smaller compared to cadaveric specimen experiments. After total laminectomy, segmental ROM increased by 9.71%, 5.79%, and 9.30% in flexion-extension, lateral bending, and axial rotation, respectively. These results suggest that in the lumbar spondylolisthesis model, the increase in ROM is greater compared to the normal lumbar spine model after total laminectomy, indicating that total laminectomy is not recommended in cases of lumbar spondylolisthesis. It is reported that the preservation of the dorsal midline structures could contribute to maintaining enough stability in the normal lumbar, bilateral laminotomy or unilateral laminectomy with “over the top” could be an alternative procedure when bilateral decompression is acquired [ 33 , 34 , 35 , 36 ]. In situations where total laminectomy is deemed necessary for decompression, it may be advisable to consider laminectomy with implantation techniques to reduce the risk of postoperative instability.

Intradiscal pressure and annulus fibrosus stress

The intradiscal pressure embodies a response from the nucleus in a state of compression [ 37 ]. As the carrying load of the nucleus increases, the IDP also increases [ 38 ], indicating a higher possibility of nucleus degeneration [ 39 ]. The IDP did not show an obvious increase tendency in both normal lumbar and spondylolisthesis models after hemilaminectomy and 1/3 facetectomy. In contrast, the IDP of total laminectomy shows an obvious increase during flexion movement. In the normal models, the IDP increased by 0.09 MPa, and in the spondylolisthesis models, the IDP increased by 0.11 MPa. The above data show that total laminectomy could easily induce the degeneration of the nucleus pulposus compared with other procedures. Compared to the normal intact lumbar model, the IDP decreased significantly in the intact spondylolisthesis model. Disc degeneration is regarded as the inducement of segment stability loss and LDS [ 4 ]. The degenerative disc loses the ability to bind water under compression, which leads to a decrease in intradiscal pressure [ 40 ]. Because of the loss of intradiscal pressure, the annulus and nucleus will bear more shear stress, which could induce the annulus tear [ 40 , 41 ].

Apart from carrying the load, the nucleus pulposus also induces tensile stress on the annulus fibrosus [ 37 ]. High stress may lead to a higher degeneration risk of annulus fibrosus; this study found that the AFS increased with the resection range. The stress of total laminectomy was higher level in both normal lumbar and spondylolisthesis models, which was consistent with previous studies [ 29 ]. The highest AFS occurred in model B2 during flexion, at 4.62 MPa, which is less than the failure strength of 8.5 MPa [ 15 ]. Although there was no significant increase in AFS compared to the intact spondylolisthesis model after facetectomy and hemilaminectomy in spondylolisthesis models, it is worth noting that the index segment AFS in intact spondylolisthesis model experienced an obvious rise compared to the intact normal lumbar model. Therefore, patients with spondylolisthesis may be at a higher risk of annulus degeneration.

Face joints contact force

As a part of a three-joint complex, facet joints play a crucial role in maintaining spine stability, especially during extension and rotation movements [ 39 , 42 , 43 ]. Previous studies have shown that the FJCF is greatest during rotation, followed by extension and lateral bending, consistent with our findings [ 44 , 45 ]. It is reported that the coronal angle of the facet joint gradually decreased and sagittal orientation increased with age, and the change of direction could lead to spondylolisthesis [ 46 ]. However, Leng et al. posit an interaction force between the lower vertebra’s superior articular process and the sliding vertebra’s inferior articular process, leading to the remodeling and morphological changes of the facet joints [ 47 ]. Morphological changes can weaken the resistance of the facet joints to anterior shear forces. When the forward shear force on the vertebra exceeds the resistance of the articular processes and posterior ligaments, it can result in lumbar spondylolisthesis. Changes in direction are a consequence of facet joint remodeling. In addition, the study of Liu et al. found The FJCF increased with the increase in the coronal angle of facet joints; they speculated that a bigger coronal angle of facet joints could contribute to bearing more mechanical load and maintaining spine stability [ 48 ].

In both normal lumbar and spondylolisthesis models, the greatest decrease in FJCF was observed with total laminectomy, followed by hemilaminectomy combined with 1/3 facetectomy and hemilaminectomy. The variation in FJCF was similar to the ROM. The capability of bearing load in facet joints is believed to be relevant to spine stability. However, high FJCF can induce facet joint arthrosis and painful articular facets [ 39 , 49 ], as the normal facet joints can bear approximately 4-25% of the total load [ 49 ]. Park et al. found that a severe degenerative spine can cause a greater FJCF [ 50 ]. Similarly, the FJCF in the intact spondylolisthesis model was larger than the intact normal model in our results. We do not observe a significantly greater decrease in the FJCF in spondylolisthesis models compared to normal lumbar models under the same surgical condition. Therefore, we believe that stability loss in lower-grade LDS is acceptable after hemi-laminectomy and facetectomy.

The isthmus was recognized as a weak area in the lumbar spine [ 37 ]. Spondylolysis is believed to result from repetitive mechanical stress on the lower lumbar vertebrae [ 51 ]. Excessive activity and stimulation of the fractured isthmus can lead to symptoms such as pain. While most individuals affected by these conditions are asymptomatic, a minority may experience chronic disabling lower back pain, sometimes radiating to the buttocks or thighs; this may be due to altered disc stress and increased disc degeneration following isthmic fracture, leading to chronic irritation [ 52 , 53 ]. Despite most surgical interventions targeting the involved motion segment, some patients may continue to experience or exacerbate symptoms even after successful bony fusion of the affected segment. Studies have shown that partial isthmic resection may increase pressure in the area [ 45 ], increasing the risk of isthmus fracture. In a study by Spina et al., it was found that more than 75% of the isthmus resection would cause the IS to approach the ultimate strength (120–140 MPa) of cortical bone; they suggested that surgeons should avoid resecting more than 50% of the isthmus [ 45 ]. We performed a pure laminectomy without destroying the isthmus, which is similar to the 0% isthmus resection in the Nicholas et al. study [ 45 ]. Our results showed that the maximal stress in the isthmus was 109.80 MPa during rotation, which is lower than the ultimate strength. However, excessive rotation moments should still be avoided. Overall, the isthmus exhibited higher stress in spondylolisthesis models and may have a higher risk of isthmus fracture during vigorous exercise.

Limitations

Some limitations in our study should be acknowledged. First, there is no suitable method of validation for developing a spondylolisthesis model, so we developed our spondylolisthesis model based on normal lumbar spine by extending the isthmus, without considering the issue of ligament pre-tension, which may not accurately reflect the morphological characteristics of lower-grader LDS. It is reported that the tropism and morphology of the facet joint could change in the LDS, which could influence the biomechanics of the motion segment [ 47 , 54 ]. Therefore, it may not fully simulate the true physiological status of spondylolisthesis. Second, due to the complexity in vivo, we simplified the model in the process. Therefore, the FE results should be considered to have a similar tendency to the actual situation and provide a possible consequence in clinical settings but not present the same mechanical behavior as in vivo. The FE results should be considered to have a similar tendency to the actual situation and provide a possible consequence in clinical settings but not present the same mechanical behavior as in vivo. Besides, there may be individual differences in each lumbar CT scan. Including differences in the height of disc space, the facet joint tropism, and bilateral asymmetry of the vertebral body, which could lead to diverse outcomes. Thus, developing multiple finite element models by adding CT data could increase the credibility of the results. Additional samples or in vitro experiments are needed to validate our findings in the future.

This study suggests that hemilaminectomy and one-third facetectomy may be viable surgical options for lower-grade LDS, with minimal impact on segment stability. However, patients with LDS undergoing hemilaminectomy and facetectomy may experience higher isthmus stress on the surgical side during rotation. In addition, total laminectomy changes the biomechanics of both normal lumbar and spondylolisthesis models.

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Department of Spine Surgery, Central South University Third Xiangya Hospital, Changsha, China

Renfeng Liu, Tao He, Xin Wu, Wei Tan, Zuyun Yan & Youwen Deng

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Ren-Feng Liu, Tao He, Wei Tan, Xin Wu carried out the model development and simulation, data analysis and drafted the manuscript.Ren-Feng Liu, Tao He, Zuyun Yan and You-Wen Deng participated in the study design. Ren-Feng Liu,Tao He, and You-Wen Deng participated in revising the manuscript. All authors read and approved the final manuscript.

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Liu, R., He, T., Wu, X. et al. Biomechanical response of decompression alone in lower grade lumbar degenerative spondylolisthesis--A finite element analysis. J Orthop Surg Res 19 , 209 (2024). https://doi.org/10.1186/s13018-024-04681-4

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Received : 16 October 2023

Accepted : 15 March 2024

Published : 01 April 2024

DOI : https://doi.org/10.1186/s13018-024-04681-4

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• Degenerative lumbar spondylolisthesis
• Laminectomy
• Decompression alone
• Biomechanics
• Finite element analysis

Journal of Orthopaedic Surgery and Research

ISSN: 1749-799X

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Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of adult isthmic spondylolisthesis

Affiliations.

• 1 Ahwatukee Sports & Spine, 4530 E. Muirwood Dr, Ste. 110, Phoenix, AZ 85048-7693, USA. Electronic address: [email protected].
• 2 Department of Neurosurgery, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226, USA.
• 3 Cleveland Clinic Center for Spine Health, 9500 Euclid Ave, Cleveland, OH 44195, USA.
• 4 University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI 48109, USA.
• 5 Department of Orthopedic Surgery, New York University School of Medicine, 550 1st Avenue, New York, NY 10016, USA.
• 6 University of Kansas Medical Center, 3901 Rainbow Blvd # 5013, Kansas City, KS 66103, USA.
• 7 The CORE Institute, 18444 N 25th Ave, Phoenix, AZ 85023, USA.
• 8 Neurological Monitoring Associates, LLC, 333 W Brown Deer Rd, Milwaukee, WI 53217, USA.
• 9 Norton Leatherman Spine Center, Department of Orthopaedic Surgery, University of Louisville, 210 E Gray St, Louisville, KY 40202, USA.
• 10 Denver Spine, 7800 E. Orchard Road, Greenwood Village, CO 80111, USA.
• 11 Department of Neurological Surgery, University of Wisconsin, 20 S Park St, Madison, WI 53715, USA.
• 12 Department of Neurosurgery, Tufts Medical Center, 800 Washington St, Boston, MA 02111, USA.
• 13 Department of Neurosurgery, Trakya University Faculty of Medicine, Edirne, Turkey 22030.
• 14 Center for Diagnostic Imaging, 5775 Wayzata Blvd, Saint Louis Park, MN 55416, USA.
• 15 Department of Neurosurgery, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI 48109, USA.
• 16 North American Spine Society, 7075 Veterans Blvd, Willowbrook, IL 60527, USA.
• 17 Spine and Pain Medicine, 655 Shrewsbury Ave, Shrewsbury, NJ 07702, USA.
• 18 Cumberland Brain & Spine, 5655 Frist Blvd, Hermitage, TN 37076, USA.
• 19 OrthoIndy, 8450 Northwest Blvd, Indianapolis, IN 46278, USA.
• 20 Rockford Health Physicians, 2350 N Rockton Ave, Rockford, IL 61103, USA.
• 21 Department of Orthopaedic Surgery, University of Tennessee-Campbell Clinic, 1400 S Germantown Rd, Germantown, TN 38138, USA.
• PMID: 27592807
• DOI: 10.1016/j.spinee.2016.08.034

Background context: The North American Spine Society's (NASS) Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Adult Isthmic Spondylolisthesis features evidence-based recommendations for diagnosing and treating adult patients with isthmic spondylolisthesis. The guideline is intended to reflect contemporary treatment concepts for symptomatic isthmic spondylolisthesis as reflected in the highest quality clinical literature available on this subject as of June 2013. NASS' guideline on this topic is the only guideline on adult isthmic spondylolisthesis accepted in the Agency for Healthcare Research and Quality's National Guideline Clearinghouse.

Purpose: The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with isthmic spondylolisthesis. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition.

Study design: This is a guideline summary review.

Methods: This guideline is the product of the Adult Isthmic Spondylolisthesis Work Group of NASS' Evidence-Based Clinical Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questionsto address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guidelines were submitted to an internal peer review process and ultimately approved by the NASS Board of Directors. Upon publication, the Adult Isthmic Spondylolisthesis guideline was accepted into the National Guideline Clearinghouse and will be updated approximately every 5 years.

Results: Thirty-one clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature.

Conclusions: The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with isthmic spondylolisthesis. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx and will remain updated on a timely schedule.

Keywords: Adult spondylolisthesis; Clinical practice guideline; Clinical practice recommendations; Evidence-based guideline; Isthmic spondylolisthesis; Spondylolisthesis; Spondylolytic spondylolisthesis.

Copyright © 2016 Elsevier Inc. All rights reserved.

Publication types

• Evidence-Based Medicine / methods*
• Evidence-Based Medicine / standards
• Neurosurgery / organization & administration
• Practice Guidelines as Topic*
• Societies, Medical
• Spondylolisthesis / diagnosis*
• Spondylolisthesis / therapy
• United States