Degenerative lumbar spondylolisthesis: Treatment strategies

Degenerative lumbar spondylolisthesis is a heterogenous entity requiring a number of different treatment strategies. Only 10-15% of patients with a symptomatic degenerative spondylolisthesis will require surgical intervention. The traditional surgical treatment has been decompression of the associated stenosis with a laminectomy and medial facetectomies. However, several studies have shown improved outcome with the addition of an intertransverse fusion. Although outcome is improved with fusion, a significant improvement in patient outcome has not been demonstrated with instrumented fusions. Thus, instrumented fusion should be reserved for patients at high risk for a progressive deformity such as patients with excessive motion on preoperative radiographs, a documented progressive slip, and those requiring a discectomy or total facetectomy to adequately decompress the neural elements. The standard type of fusion has been a posterolateral intertransverse fusion with autologous bone. An interbody fusion may be advantageous when there is severe disc space collapse with narrowing of the neuroforamen, when a discectomy is performed as part of the decompression, or to correct a kyphosis at that motion segment. Randomized, controlled outcome studies evaluating the use of instrumented fusions in subsets of patients with degenerative spondylolisthesis are needed.