CHAPTER
Steven S. Agabegi
63
Adult Degenerative Spondylolisthesis
Without Lysis
BACKGROUND DATA
Spondylolisthesis is the anterior sagittal slippage of a vertebra
on its adjacent caudal segment and can result from a number
of different disease processes. Wiltse et al developed a classifica-
tion system, which included congenital, isthmic, degenerative,
pathologic, iatrogenic, and traumatic causes of spondylolisthe-
sis.29 Marchetti and Bartolozzi divided the causes of spondylolis-
thesis into developmental (or dysplastic) in which there is a
morphologic abnormality in anatomy, and acquired spon-
dylolisthesis, in which the anatomy is normal and the slip is due
to degenerative, traumatic, or pathologic causes.18 The former
is much more prone to progression than the latter due to the
underlying abnormality in the anatomy.
The most common cause of spondylolisthesis in adults is
degenerative. Unlike isthmic spondylolisthesis, the posterior
neural arch remains intact. Degenerative slips are much more
common in women, presumably because of increased ligamen-
tous laxity, and in patients of African descent, presumably
because of decreased lumbar lordosis and increased sacraliza-
tion of L5, which can create increased force across the L4-5
segment. It most commonly occurs at L4-5, which has more
sagittally oriented facet joints. The L5-S1 facet joints have a
more coronal orientation, and it is rare to have a degenerative
spondylolisthesis at L5-S1 without a defect in the pars interar-
ticularis. The restraining effect of the iliolumbar ligaments on
L5 also prevents slips at L5-S1 while predisposing L4 to slip
forward.
The spinal functional unit consists of three joints: the
intervertebral disc and two facet joints. Whether disc degenera-
tion or facet degeneration initiates the degenerative cascade is
unclear and there is evidence for both. But historically, the
focus has been mostly on disc degeneration as the initiating
event in the degenerative cascade. Chronic disc degeneration
leads to altered stress loading of the facet joints with resultant
laxity in facet joint capsules and the supporting ligamentous
structures. These changes lead to segmental instability, which
represents abnormal motion between two or more vertebrae,
and encompasses rotatory subluxation, degenerative scoliosis
and degenerative spondylolisthesis.
LWBK836_Ch63_p617-632.indd 617
David M. Montgomery
Harry N. Herkowitz
CLINICAL FEATURES
Spinal stenosis commonly coexists with degenerative spon-
dylolisthesis. The degenerative changes that lead to hypertro-
phy of the facet joints and ligamentum flavum create narrowing
of the spinal canal at the unstable segment. Patients usually
present with low back pain and neurogenic claudication, con-
sisting of unilateral or bilateral leg and buttock pain that is
worse with activity and is improved with rest or lumbar spine
flexion. If stenosis is severe, bowel or bladder dysfunction may
occur, although this is very rare.
IMAGING STUDIES
An anteroposterior (AP), standing lateral, and lateral flexion/
extension views of the lumbar spine should be obtained. The flex-
ion and extension views should be scrutinized for motion at the
olisthesed segment. A magnetic resonance imaging (MRI) scan
should be done if neurologic symptoms and/or signs are present.
If MRI is contraindicated (e.g., pacemaker, cochlear implant), a
computed tomography (CT) myelogram can be obtained to eval-
uate for stenosis and neural element compression. In many cases,
the spondylolisthesis reduces in the supine position and minimal
or no slip may be seen on the sagittal MR images or on supine
radiographs. Therefore, standing flexion/extension radiographs
should always be obtained (see Case 63.7).
NATURAL HISTORY
Matsunaga et al followed 40 patients with degenerative spon-
dylolisthesis treated nonoperatively for at least 5 years. Thirty
percent of patients had progression of the slip, which rarely
exceeded 30%.21 No progression of slippage was noted in
patients who showed narrowing of the disc, spur formation,
subcartilaginous sclerosis, or ossification of intervertebral liga-
ments. Physiologic secondary stabilization of the unstable seg-
ment does occur and may lead to resolution or improvement in
symptoms. In a follow-up of this study, Matsunaga et al reported
617
8/17/11 10:59:49 AM
 618 Section VI Spondylolisthesis

on 145 patients with degenerative spondylolisthesis who were
treated nonoperatively for a minimum of 10 years.20 Thirty-four
percent of patients had progressive spondylolisthesis, which
was not correlated with clinical symptoms. Seventy-six percent
of patients with no neurologic deficits at initial examination
remained neurologically intact at follow-up. Eighty-three per-
cent of patients with neurogenic claudication experienced neu-
rological deterioration.
In general, the natural history of degenerative spondylolis-
thesis is favorable, as only 10% to 15% of patients seeking treat-
ment will eventually have surgery.25 Furthermore, the amount
of slippage in degenerative spondylolisthesis is limited by the
intact neural arch and rarely exceeds 30% of vertebral width.20
NONOPERATIVE TREATMENT
A prolonged course of nonoperative treatment is appropriate (at
least 12 weeks) before surgery is considered. The decision to
perform surgery is based on the severity of symptoms and the
degree of disability experienced by the patient. If symptoms are
debilitating and affect activities that the patient enjoys, surgery
can be considered. The only absolute indications for surgery are
progressive neurologic deficit and cauda equina syndrome, both
of which are very rare in this condition. As mentioned previously,
natural history studies show that most patients with degenerative
spondylolisthesis do not worsen with time. Therefore, nonopera-
tive treatment consisting of anti-inflammatory medications, phys-
ical therapy, and aerobic conditioning is the initial mainstay of
treatment. Aerobic exercise in the form of stationary bicycling,
swimming, walking, and elliptical machines are good forms of
cardiovascular exercise. Patients with neurogenic claudication
and radicular symptoms may benefit from epidural steroid injec-
tions, although the relief may be temporary.
In general, patients who have significant disability due to
neurogenic claudication or radicular pain, resulting in a sig-
nificant reduction of quality of life, despite nonoperative treat-
ment of at least 3 months, are the best candidates for surgery.
Patients complaining primarily of low back pain despite conser-
vative treatment of at least 6 months can be considered for sur-
gery. The outcome for relief of back pain is not as predictable
as relief of radicular symptoms in the extremities.
Recently, the Spine Patient Outcomes Research Trial (SPORT)
compared the effectiveness of surgical and nonsurgical treat-
ment in patients with degenerative spondylolisthesis.28 Three
hundred four patients were enrolled in the randomized cohort
and 303 in the observational cohort. Patients treated surgically
showed substantially greater improvement in pain and function
during a period of 2 years than do patients treated nonsurgically.
Extensive crossovers occurred between the surgical and nonsur-
gical groups in the randomized arm of the study, and the above
result was based on an as-treated comparison. Despite this, con-
founding variables were carefully matched between the surgical
and nonsurgical groups. This landmark study provides the high-
est level of evidence to date on the efficacy of surgical versus
nonsurgical treatment in patients with degenerative spondylolis-
thesis who have failed a course of nonoperative treatment.
SURGICAL TREATMENT OPTIONS
Surgical options for degenerative spondylolisthesis include
decompression alone, decompression with posterolateral fusion
(with or without instrumentation), and interbody fusion per-
formed through an anterior (anterior lumbar interbody fusion
or ALIF) or posterior (posterior or transforaminal lumbar
interbody fusionPLIF or TLIF) approach. The goals of sur-
gery depend on the patients symptoms and findings on imag-
ing studies. If neurogenic claudication or radicular symptoms
predominate, decompression of the neural elements is the pri-
mary goal. Preoperative imaging studies should be carefully
assessed to determine the stenotic areas that require decom-
pression (e.g., central, lateral recess, and/or foraminal steno-
sis). Fusion is very controversial for the treatment of low back
pain due to degenerative disc disease without instability. How-
ever, a fusion is generally recommended when decompressing
nerve roots in the presence of structural instability, whether
due to spondylolisthesis or scoliosis (with lateral listhesis).
Despite a general consensus to fuse unstable segments, there is
some support in the literature for decompression without
fusion for degenerative spondylolisthesis (Table 63.1). Decom-
pression alone may be an acceptable option in select elderly
patients who do not have motion on flexion/extension views to
avoid the higher morbidity and mortality associated with a
fusion. If this approach is used, patients should be counseled
about the possibility of requiring a second operation to perform
a fusion if symptoms persist or if gross instability develops.
Patients commonly require extension of the decompression
to stable levels above or below a spondylolisthesis. For example,
a patient with degenerative spondylolisthesis at L4-5 may also
have stenosis at adjacent segments without spondylolisthesis.
Decompression of all stenotic segments that may be causing
the patients radicular symptoms is recommended, but fusion
should only be performed at the unstable segment, unless the
decompression produces instability of adjacent segments
(Cases 63.1, 63.4, and 63.6). Alternatively, interlaminar
decompression, in which the spinous process, interspinous lig-
aments, and facet joints are preserved, may allow effective
decompression without causing iatrogenic instability that may
result from a full laminectomy. Radiographs should be care-
fully scrutinized for any evidence of instability at the other
stenotic segments. If preoperative instability exists, such as ret-
rolisthesis or lateral listhesis, then the fusion should incorpo-
rate these segments. In addition, segments destabilized by
removing a significant portion of the facet joint or pars interar-
ticularis should be fused. The relationship between radio-
graphic evidence of degenerative disease in the lumbar spine
and clinical symptoms is inconsistent and fusion should only be
performed for structural instability.
The type of fusion that is performed (posterolateral with or
without instrumentation and/or interbody fusion) for degen-
erative spondylolisthesis is controversial. Several well-designed
studies are available to guide treatment decisions regarding the
use of instrumentation. However, there is a lack of solid evi-
dence supporting the addition of interbody fusion for this indi-
cation. These issues will be explored in more depth below.
POSTEROLATERAL FUSION
The need for posterolateral fusion with and without instrumen-
tation has been addressed in several studies (Table 63.2), three
of which are prospective randomized trials. In general, combin-
ing fusion with decompression provides better clinical results for
degenerative spondylolisthesis than decompression alone.2,7,30
Although the addition of instrumentation to a posterolateral

LWBK836_Ch63_p617-632.indd 618 8/17/11 10:59:49 AM

 Chapter 63 Adult Degenerative Spondylolisthesis Without Lysis 619

TABLE 63.1 Evidence for Decompression Without Fusion

Comparison
Study Study Design Group Mean f/u Outcomes/Comments
Epstein and Epstein3 Retrospective None 10 y 69% excellent; 13% good; 12% fair; 6% poor results
Case series (290 Only patients with 4 mm of translation and 1012 of
patients) angulation on dynamic lateral X-rays included; only 8/290
patients required revision surgery for instability or restenosis.
Kristof et al14 Retrospective None 3.73 y 73.5% excellent or good results; 10% underwent revision with
Case series (49 instrumented fusion; patients had no evidence of
patients) hypermobility on dynamic lateral X-rays.
Mardjetko et al19 Meta-analysis (216 69% satisfactory; 31% unsatisfactory; 31% progressive slip; based
patients) on 11 papers, 2 were randomized.
Kleeman et al12 Prospective (54 None 4y 87% had no progression of slip (13/15); 88% good/excellent
patients, only 15 results.
had degenerative
spondylolisthesis)
Herron and Trippi8 Retrospective case None 34 mo 20 good, 3 fair, 1 poor result. Mean slip increased by 1 mm from
series (24 pre to postop; no patient had an increase in slip of greater
patients) than 4 mm.

fusion improves the fusion rate, its effect on clinical outcome is
somewhat controversial. The evidence seems to suggest that
long-term clinical outcome is improved with instrumentation
because of the higher fusion rate, but short-term outcome is
not significantly impacted.4,13 Despite the widespread use of spi-
nal instrumentation, an uninstrumented posterolateral fusion
is still a viable option in elderly patients with degenerative spon-
dylolisthesis who have no segmental motion on flexion/exten-
sion radiographs.
In 1994, Mardjetko et al performed a meta-analysis of 25
articles published between 1970 and 1993, reporting on 889
patients with degenerative spondylolisthesis who had under-
gone decompression alone, or decompression with posterolat-
eral fusion with and without instrumentation.19 The fusion and
instrumentation group had a 93% fusion rate and a satisfaction
rate of 86%, whereas the noninstrumented fusion group had
an 86% fusion rate and a 90% satisfaction rate. The group that
underwent decompression alone without fusion had only a
69% satisfactory outcome, and 31% had progression of the slip-
page. This analysis showed that fusion improves clinical out-
comes but the benefit of instrumentation is not clear.
INTERBODY FUSION
In recent years, interbody fusion has become increasingly com-
mon using ALIF, PLIF, or TLIF in the treatment of degenera-
tive disorders of the lumbar spine (Case 63.2). In general, high
fusion rates and good to excellent clinical outcomes have been
reported.17 However, treatment efficacy has not been estab-
lished because the studies are primarily retrospective case
series, those that are prospective lack a comparison group, and
objective and validated functional outcome scales are not con-
sistently used. To our knowledge, there is only one prospective
randomized study comparing posterolateral fusion, PLIF, and
PLIF combined with posterolateral fusion for degenerative
conditions of the lumbar spine.10 There were no significant dif-
ferences in the clinical results and fusion rates between the
three fusion methods. However, this study has several limita-
tions: a mixed group of patients with degenerative conditions
of the lumbar spine was included, the randomization process is
not described, it is not clear how patients were allocated to dif-
ferent treatment groups, analysis was not performed on an
intent-to-treat basis, and it cannot be determined whether any
measures were taken to conceal the allocation process.
The disadvantages of including an interbody device include
the added cost, increased operative time, the risk of neurologic
injury due to nerve root or dural sac retraction, and the long-
term, potentially deleterious effects of complete immobiliza-
tion of a motion segment on the adjacent lumbar levels. In the
absence of a well-designed, prospective randomized study com-
paring the clinical outcome of posterolateral fusion with or
without concomitant interbody fusion for degenerative spon-
dylolisthesis, definitive statements about treatment efficacy can-
not be made. Although one would expect fusion rates to be
higher with the addition of an interbody fusion, it is not clear
whether clinical outcomes would be improved.
There are no established guidelines in the literature on
whether a PLIF or TLIF is preferred over a posterolateral
fusion. Therefore, any recommendation on which procedure
should be performed in any particular patient, other than to
perhaps improve the fusion rate, is anecdotal and not based on
good evidence. Proponents of interbody fusion argue that disc
height and lumbar lordosis are restored, thereby improving
overall sagittal balance and increasing foraminal height for an
indirect decompression. However, a recent study found that
while an ALIF restored foraminal height by 18.5% and lumbar
lordosis by 6.2, TLIF decreased foraminal height by 0.4% and
lumbar lordosis by 2.1.9 At the time of this writing, this is the
only study directly comparing these two approaches for inter-
body fusion.
The above study9 highlights an often-neglected technical
detail that limits the ability of the TLIF to adequately restore
foraminal height or lordosis. It is very difficult, to remove a
substantial portion of the disc space through a unilateral
TLIF approach. To adequately restore disc space height and
foraminal height, it is necessary to release the annulus fibro-
sus circumferentially, which can best be performed through
an anterior approach. It is doubtful that a TLIF procedure

LWBK836_Ch63_p617-632.indd 619 8/17/11 10:59:49 AM

 620 Section VI Spondylolisthesis

TABLE 63.2 Evidence for Fusion With/Without Instrumentation

Study Study Design Comparison Groups Mean f/u Outcomes/Conclusions

Herkowitz Prospective, DLL (25 patients). 3y 96% of fused group had satisfactory outcome, compared
et al7 randomized DLL PLF (25 with 44% of unfused group; pseudarthrosis (36% rate)
patients) did not preclude a successful outcome. Slip
progression occurred in almost all of the unfused
spines.
Zdeblick30 Prospective, 3 groups: PLF (51 16 mo Fusion rate with rigid instrumentation (86%) higher
randomized patients) vs. PLFI than without instrumentation (65%); outcome data
(rigid) (35 not separated by diagnosis to compare results
patients) vs. PLFI specifically in patients with degenerative
(semirigid) (37 spondylolisthesis; clinical outcomes determined by
patients) evaluation of work status, pain medication usage, and
level of discomfort.
Bridwell et al2 Prospective cohort 3 groups: DLL (9 At least 2 y Improved fusion rates with instrumented fusion;
Nonrandomized patients) vs. DLL functional improvement in 83% of instrumentation
PLF (10 group, 30% of uninstrumented group and 33% of
patients) vs. DLL decompression group.
PLFI Functional assessment determined only by patients
(24 patients) ability to walk longer (improved) or shorter (worse)
distances after surgery than before surgery; slip
progression significantly less in patients who had
pedicle screw instrumentation.
Fischgrund JS Prospective, DLL PLF (33 2 y minimum Fusion rate higher in instrumented group (82% vs. 45%).
et al4 randomized patients) vs. DLL No difference in clinical outcome. Concluded that
PLFI (35 instrumentation improves fusion rate but not clinical
patients) outcome at 2 y.
Kornblum Prospective, Solid fusion (22 514 y Group with solid fusion had better clinical outcomes
et al13 randomized patients) vs. than the group with pseudarthrosis; concluded that
pseudarthrosis instrumented fusion gives better outcome long-term.
(25 patients)
Kimura et al11 Retrospective case- DLL PLF (29 2y No difference between the two groups with regard to rate
control patients) vs. DLL of fusion or rate of satisfactory outcome.
PLFI (28
patients)
Nork et al22 Retrospective case No comparison 2 y minimum 93% of patients satisfied with outcome; SF-36 was used
series group: DLL but only postoperatively and results were compared
PLFI (30 with population norms.
patients)
Ghogawala Prospective cohort DLL (20 patients) 1 y minimum Both groups improved but fusion group had substantially
et al5 Nonrandomized vs. DLL PLFI improved outcomes in regards to Oswestry and SF-36.
(14 patients)

DLL, decompressive lumbar laminectomy; PLF, posterolateral fusion (no instrumentation); PLFI, posterolateral fusion with instrumentation.

substantially increases foraminal height to the degree neces-
sary to relieve nerve root compression. Direct foraminal
decompression is therefore recommended in any patient with
significant radicular symptoms and one should not rely on
indirect decompression techniques as the sole means of
treating radicular symptoms. Furthermore, loss of lumbar lor-
dosis or sagittal imbalance is rarely present in degenerative
spondylolisthesis. Arguments to support a TLIF for any of
these indications are subject to critique and lack supportive
clinical evidence.
The addition of spondylolisthesis to a stenotic segment
changes the pattern of nerve root compression. For example,
most patients with spinal stenosis at L4-5 manifest symptoms
due to L5 root compression in the lateral recess (Fig. 63.1).
The addition of a slip at the L4-5 level profoundly affects the
L4 nerve root in the foramen. Sagittal MR images through
the foramen often show that the L4 root is compressed
between the L4 pedicle and the L4-5 disc (see Fig. 63.2 and
Case 63.3). If there is significant foraminal stenosis, the expo-
sure for a transforaminal interbody fusion will allow complete
decompression of the nerve root. Because the pars, facet
joint, and the foraminal disc are removed during a TLIF pro-
cedure, decompression of the L4 nerve root in the foramen is
facilitated. The addition of an interbody fusion to this well-
performed decompression may increase the likelihood of a
solid fusion.
It appears that the most compelling reason to perform a
TLIF is to improve fusion rates. There is little doubt that a cir-
cumferential fusion leads to higher fusion rates and more rigid
immobilization of a motion segment. What is not known is
whether circumferential fusion, which presumably eliminates
almost all motion at that level, leads to improved clinical out-
comes compared with posterolateral fusion alone. How much
rigidity at one or more levels is required for a clinically success-

LWBK836_Ch63_p617-632.indd 620 8/17/11 10:59:50 AM


Figure 63.1. Figure showing lateral recess stenosis and foraminal
stenosis. The latter is more common in degenerative spondylolisthesis
as the exiting nerve root (L4) is compressed between the L4 pedicle
and the L4-L5 disc in the foramen. In spinal stenosis (without a slip),
the L5 nerve root is more likely to be compressed in the lateral recess.
ful outcome? It is a biomechanical principle that more rigid
stabilization of one level leads to increased motion and stress at
adjacent levels. In light of the lack of clinical evidence of the
superiority of a circumferential fusion, the potentially deleteri-
ous effects of more rigid immobilization of a motion segment
on the adjacent levels must be carefully considered. The prob-
Dural
sac
L4
pedicle
L4 nerve
root
L4-5
disc
Figure 63.2. Intraoperative photograph showing the concept dis-
cussed in Figure 63.1. After the nerve root has been deroofed posteri-
orly (pars resected), it is still being compressed between the L4
pedicle and the L4-5 disc. The compressive disc material must be
removed to adequately decompress the root.
LWBK836_Ch63_p617-632.indd 621
Chapter 63 Adult Degenerative Spondylolisthesis Without Lysis 621
lem of adjacent segment degeneration will be further discussed
later in this chapter.
SURGICAL TECHNIQUES
DECOMPRESSION
The extent of decompression that is necessary depends on
the location and degree of stenosis. Most patients with degen-
erative spondylolisthesis have central and bilateral lateral
recess stenosis, even if they have unilateral radicular symp-
toms. In addition, foraminal stenosis is more common in
degenerative spondylolisthesis than in spinal stenosis without
spondylolisthesis. As mentioned above, in a typical L4-5 spon-
dylolisthesis, the L4 nerve root is likely to be compressed in
the neural foramen (Fig. 63.1 and Case 63.3), whereas in a
typical case of spinal stenosis (without spondylolisthesis) at
the same level, the traversing L5 nerve root is more commonly
compressed in the lateral recess. Therefore, careful decom-
pression of the neural foramen is very important in these
patients.
Traditionally, a midline laminectomy with decompression of
bilateral lateral recesses and neural foramina has been per-
formed. The patient is positioned with the hips extended to
simulate the upright posture. This position is preferred when-
ever a fusion is planned (which is usually the case in spon-
dylolisthesis) and also places more compression on the neural
elements, allowing the surgeon to more accurately assess the
necessary degree of decompression. Fusing the spine in a flexed
position can lead to a flatback deformity.
After standard exposure of the posterior spine with radio-
graphic confirmation of the proper level, a Leksell rongeur is
used to remove the spinous processes and the interspinous liga-
ment. When the lamina is adequately thinned with a Leksell
rongeur, a small curet can be used to gain entry to the spinal
canal between the ligamentum flavum and the lamina. A
Kerrison rongeur is used to remove the laminae in a caudad to
cephalad direction. Once the central canal is decompressed,
attention is then directed to decompression of the lateral
recesses and the neural foramina. From the opposite side of
the table, the medial border of the superior articular process is
undercut with a Kerrison out to the medial border of the pedi-
cle. The traversing nerve root lies just medial to the medial bor-
der of the pedicle and can be followed out into the foramen
just inferior to the pedicle. The lateral recess is decompressed,
if the nerve root is free of compression up to the point of the
medial edge of the pedicle.
The pars interarticularis is then undercut to decompress the
neural foramen. If a fusion is planned, the entire pars interar-
ticularis may be removed to thoroughly decompress the neural
foramen. Leaving some of the pars does provide additional sta-
bility even with a fusion and in most cases, undercutting the
pars allows adequate decompression of the nerve root. There
are no clear guidelines on how much of the pars to leave intact.
More of the pars should be preserved in patients with osteopo-
rosis because a thin pars may fracture postoperatively. If a
fusion is planned and significant foraminal stenosis is present,
it is preferable to remove more of the pars to ensure complete
decompression of the nerve root.
The key landmark in successful decompression of the lateral
recess and the neural foramen is the pedicle. The nerve root
8/17/11 10:59:50 AM
 622 Section VI Spondylolisthesis
hugs the medial border of the pedicle in the lateral recess and
subsequently hugs the inferior border of the pedicle out into
the neural foramen. The Kerrison rongeur should correspond-
ingly follow the pedicle in these regions, decompressing the
nerve root as the compressing bone spurs and ligamentum
flavum dorsal to the nerve root are removed. It is important to
be in the correct plane just above the nerve root with the foot
plate of the Kerrison to remove all compressive structures. A
hockey stick or Woodson can be used to assess the adequacy of
decompression. Decompression is complete when a hockey
stick can be easily passed out of the neural foramen, both dor-
sal and ventral to the nerve root.
POSTEROLATERAL FUSION
There are several key elements of the exposure that should be
observed when performing a posterolateral fusion. Exposure of
the dorsal surface of the transverse processes is sufficient. Violat-
ing the intertransverse ligaments risks excessive bleeding and
injury to the exiting nerve roots, which lie in the neural foramen
located anterior to these ligaments. Also, it is critical that the
facet joint capsules of the level above the intended level of fusion
be preserved. A Cobb elevator is used to strip the soft tissue off
the capsule without disrupting the capsule itself. The junction of
the transverse process and the superior articular process is iden-
tified and cleaned of soft tissue to expose the entry point of the
pedicle screw. If L5-S1 fusion is planned, it is important to expose
the sacral ala, which lies just lateral to the L5-S1 facet joint.
For a posterolateral fusion (intertransverse process fusion), the
fusion bed consists of the dorsal aspect of the transverse process,
the facet joint, and the pars interarticularis. Therefore, decortica-
tion of these anatomic regions with a power burr is performed.
Prior to decortication, all soft tissues that overlie the transverse
process and the lateral aspect of the facet joint are removed.
To properly decorticate the transverse processes (and the
sacral ala), it is helpful to decorticate these areas before pedicle
screws are placed because the screw heads will make exposure
of these regions very difficult. After the pedicle finder is used to
prepare the screw tract and tapping is performed, the trans-
verse process and the lateral aspect of the facet joint can be
decorticated before placing the pedicle screw at each level. For
lumbosacral fusions, the sacral ala is decorticated to the depth
of the L5 transverse process.
After pedicle screws have been placed and decompression is
performed, rods are inserted into pedicle screws and set screws
are placed. Bone graft is then placed over the decorticated
areas in the lateral gutters. Local bone graft harvested during
the decompression can be placed into a bone mill device that
grinds bone into a corticocancellous mush.
TRANSFORAMINAL LUMBAR INTERBODY FUSION
A standard PLIF requires bilateral exposure with insertion of
cages on both sides. With a TLIF, only one side is exposed and the
interbody work is done from that side. Pedicle screws can be
placed before or after the decompression. During the TLIF pro-
cedure, the extent of decompression depends on the patients
symptoms and location of stenosis on preoperative imaging stud-
ies. Bilateral decompression can be performed if necessary, but a
standard TLIF allows decompression of the neural foramen and
the lateral recess on the symptomatic side. The entire facet joint
on one side is removed. The exiting nerve root is identified and
LWBK836_Ch63_p617-632.indd 622
decompressed by removing the pars interarticularis. The disc
space is identified just cephalad to the pedicle. The working space
is between the thecal sac medially, the pedicle inferiorly, and the
exiting nerve root superolaterally. Rarely, one may encounter
abnormal lumbar nerve root anatomy such a low takeoff of the
exiting nerve root from the thecal sac, or a conjoined nerve root
within the foramen. These anomalies can place the nerve root at
risk for iatrogenic injury as the disc space is approached.
Once the disc space is identified, an annulotomy is made
and discectomy is performed. The next step is to restore disc
space height using sequentially larger disc space dilators. The
disc and the cartilaginous end plate are removed, leaving the
bony end plates intact. Removal of the bony end plates predis-
poses to subsidence of the interbody device.
Trial implants for the cage to be used are then used to assess
optimal size. The cage is packed with autogenous local cancel-
lous bone or bone morphogenetic protein (BMP), and it is
impacted into the disc space. Prior to inserting the cage, autog-
enous cancellous bone (usually local bone) can be packed into
the anterior disc space. Insertion of the cage is the portion of the
procedure that is associated with the greatest risk of neurologic
injury. The exiting nerve root should be well visualized and care-
fully protected during this step. It is important to have a lateral-
to-medial trajectory when inserting the cage so that it crosses the
midline. The interbody device should be slightly countersunk
relative to the posterior vertebral body.
After the interbody device is inserted, the rods are placed.
Mild compression can be applied across the pedicle screws to
lock the cage in position, but we do not feel that this step is
absolutely necessary. The remainder of the procedure is similar
to that described above for a posterolateral fusion.
POSTOPERATIVE MANAGEMENT
Most patients are mobilized to a chair on the evening of sur-
gery and are encouraged to ambulate with the aid of a physical
therapist on the first postoperative day. Compression stockings
are used for deep venous thrombosis prophylaxis. The subfas-
cial drain is usually removed on postoperative day 1 or 2. Aspi-
rin and anticoagulants are avoided for 1 week. Patients are
typically discharged in 2 to 4 days. Elderly patients sometimes
require transfer to a rehabilitation facility. Patients are seen 2
weeks after surgery for radiographs and staple removal. There-
after, they are evaluated every 3 months with repeat radiographs
at every visit until the 1 year postoperative visit.
COMPLICATIONS OF SURGICAL
TREATMENT
Complications encountered in the surgical treatment of degen-
erative spondylolisthesis include intraoperative complications
that may occur during any spine operation, such as dural tears
and nerve root injury, to delayed complications such as pseu-
darthrosis and adjacent segment disease. Wound infections and
complications related to pedicle screw instrumentation will be
discussed in Chapter 66. Delayed complications will be dis-
cussed in more depth here.
Dural tears that are repaired primarily typically do not cause
any adverse sequelae. The management of dural tears will be
discussed in more detail in later Chapter. Even with the best sur-
9/26/11 10:10:39 PM

gical technique, nerve roots may be temporarily irritated due to
intraoperative retraction and manipulation. Permanent damage
to the nerve root, while rare, may occur. Good surgical
technique minimizes these complications. In general, dural
retraction should be kept to a minimum. If prolonged retrac-
tion is needed, periods of relaxation should be allowed by let-
ting go of the retractors. If a TLIF is being performed, the exit-
ing nerve root should be visualized and protected during
insertion of the cage, which is the most hazardous portion of
the operation in terms of risk of neurologic injury.
PSEUDARTHROSIS
The incidence of pseudarthrosis in the lumbar spine is highly
variable in the literature, reflecting the varying radiographic
criteria used to make this diagnosis. Patients who ultimately
develop pseudarthrosis are generally asymptomatic or mini-
mally symptomatic in the early postoperative period. If decom-
pression and instrumentation were performed, relief of leg
pain and the stability afforded by instrumentation often leads
to an improvement in symptoms. However, as pseudarthrosis
develops, residual instability leads to progressive pain with time.
In general, one should wait at least 12 months before defini-
tively diagnosing a pseudarthrosis.
In the absence of progressive deformity, hardware failure or
interbody device migration, the diagnosis of a pseudarthrosis
can be challenging. In most cases, a pseudarthrosis presents
with persistent low back pain with or without lower extremity
radiculopathy. Bone scans and single-photon emission com-
puted tomography (SPECT) scans generally lack sensitivity
and specificity and are rarely helpful. Standard radiographic
views (including flexion and extension lateral radiographs)
and a CT scan are the recommended imaging studies. If there
is bridging bone between the transverse processes and no
motion on flexion/extension films, a solid fusion is believed to
have occurred. The persistence of a radiographic cleft or the
presence of motion on flexionextension lateral radiographs
implies that a pseudarthrosis may be present. However, the
amount of motion that signifies a pseudarthrosis is not known.
Furthermore, instrumentation can obscure the visualization of
bridging bone and may also prevent dynamic motion on flex-
ionextension views, even if a pseudarthrosis is present.
CT scan with coronal and sagittal reconstruction views is
more reliable than plain radiographs but must be interpreted
with caution. The presence of bone resorption and halo forma-
tion around screws suggests pseudarthrosis, but the lack of
these findings does not necessarily indicate the presence of a
solid fusion. A stable fibrous union in a patient with persistent
postoperative back pain may be interpreted as a pseudarthrosis
on a CT scan and may lead to unnecessary interventions.
Lucency around pedicle screws may indicate loosening of
the screw. This motion may have predisposed to a pseudarthro-
sis. Broken hardware does not necessarily mean that a pseudar-
throsis is present but should raise the suspicion of a pseudart-
hrosis and prompt further investigation. In the absence of
infection, it is generally not necessary to remove broken hard-
ware unless vital structures (vessels, neural elements) are at risk
of injury due to migration of the hardware or interbody device.
The hardware may have failed during the fusion process as it
was exposed to repeated stresses causing fatigue failure.
Infection should be ruled out in any patient who is diag-
nosed with pseudarthrosis. Laboratory studies (C-reactive protein
LWBK836_Ch63_p617-632.indd 623
Chapter 63 Adult Degenerative Spondylolisthesis Without Lysis 623
and erythrocyte sedimentation rate) should be obtained.
Patients with persistent low back pain should also be evaluated
for adjacent segment disease, which may be present even in the
presence of pseudarthrosis and may need to be addressed.
Patients with lumbar pseudarthrosis may be managed con-
servatively in the absence of neurologic compromise or defor-
mity progression. However, after 1 year, it is not likely that the
pseudarthrosis will fuse. In the absence of infection, surgical
options for an established pseudarthrosis include ALIF, circum-
ferential fusion via either combined anterior and posterior
approaches or a posterior only approach (TLIF), or revision
posterolateral fusion. All of these options have a role depending
on the clinical circumstances. Factors that guide the approach
include the approach used in the index procedure, as well as
the need for nerve root decompression, deformity correction,
and removal of migrated implants or broken hardware.
An ALIF is an excellent option for a failed posterolateral
fusion. It allows correction of kyphotic deformity and provides
increased bony surface area for fusion compared with a postero-
lateral fusion. This approach is also ideal for removing a migrated
interbody device that had previously been placed through a pos-
terior approach. It has been our experience that removal of
these devices from a posterior approach is challenging with a
high risk of dural tear and nerve root injury due to the presence
of scarring around the roots from the prior surgery (usually a
TLIF). The anterior approach allows for removal of the device in
a controlled fashion without risking injury to the nerve roots. If
the patient has radicular symptoms as well, removal of the
migrated interbody device, which may be impinging on neural
structures, may relieve these symptoms. If radicular symptoms
persist after removal of the cage, then a posterior revision decom-
pression can be performed at a later setting.
In a patient with a failed anterior interbody fusion, a repeat
anterior exposure may be technically difficult due to the pres-
ence of scarring, especially at L4-5. A posterior approach may
be preferred in these cases, with iliac crest autograft and care-
ful decortication of the transverse processes and facet joints.
Iliac crest autograft should be strongly considered in patients
undergoing pseudarthrosis repair.
Recombinant BMP-7 is currently approved by the U.S.
Food and Drug Administration under a Humanitarian Device
Exemption (HDE) as an alternative to autograft in compromised
patients (smokers, diabetics, osteoporosis) who need revision pos-
terolateral fusions. Off-label use of bone morphogenic proteins
should be discouraged until more data are available. In addition,
risk factors for pseudarthrosis (including tobacco use and use of
NSAIDs) should be eliminated if possible.
ADJACENT SEGMENT DISEASE
Various abnormal processes have been characterized as adjacent
segment disease after spinal fusion, including disc degeneration,
segmental instability (retro- or anterolisthesis), herniated nucleus
pulposus, spinal stenosis, vertebral compression fracture, and
osteophyte formation.23 Risk factors for adjacent segment degen-
eration include the use of instrumentation, longer fusion con-
structs, PLIF, sagittal malalignment, facet injury, advanced age,
and preexisting degenerative changes.23
The incidence of symptomatic adjacent segment disease
ranges from 5.2% to 18.5%,23 although the incidence of radio-
graphic adjacent segment changes is much higher. Lehmann
et al reported the incidence of adjacent segment degeneration
8/17/11 10:59:53 AM
 624 Section VI Spondylolisthesis
(defined by segmental instability above the fused level) to be
45%, but these radiographic changes did not correlate with
clinical symptoms and only 5% of all patients underwent a sec-
ond lumbar surgery.16
There is extensive in vitro and in vivo biomechanical evi-
dence using both animal and human cadaveric spine models
that fusion at one level is associated with increased motion and
stress at adjacent levels. In general, the more rigid the fusion,
the more stress is transferred to the adjacent segments. The
clinical relevance of this fundamental biomechanical concept is
in regards to the addition of interbody fusion, which creates a
more rigid fusion construct compared with posterolateral fusion
alone. Biomechanical studies have been conducted to assess the
changes in adjacent segments after posterior, anterior, and cir-
cumferential fusion. In general, these studies demonstrate that
compared with a posterolateral fusion alone, the addition of an
interbody fusion increases loads at the adjacent segments.15,26, 27
The etiology of adjacent segment degeneration is not fully
understood, although several theories exist. Adjacent segment
degeneration may be a manifestation of the progression of
existing degenerative changes in the spine of predisposed indi-
viduals, but the large amount of biomechanical evidence cer-
tainly suggests that the increased motion and stress that occur
at adjacent segments to a fusion plays a significant role. Whether
posterolateral fusion alone reduces this risk compared with a
circumferential fusion has not been clinically proven, although
biomechanical studies support this assertion.
In some cases, adjacent segment problems are due to errors
in surgical technique. Violation of the adjacent superior seg-
ment facet joint can accelerate degenerative changes in these
joints over time. During the exposure, the facet joint capsule of
the cephalad segment should be preserved by using a Cobb to
sweep the soft tissue off the facet capsule laterally. A relatively
more lateral starting point for these pedicle screws (at the
transverse processfacet junction) and angling the trajectory in
a more medial direction can minimize screw impingement on
the facet joint. Attention should also be paid to a rod that is
excessively long at the cephalad end of the construct, which
may impinge on the joint. Following these principles may help
decrease the incidence of adjacent segment problems.
Most patients with adjacent segment degeneration are asymp-
tomatic. In the symptomatic patient, the dilemma is in determin-
ing whether the changes in the adjacent segment are causing the
symptoms. After an appropriate course of nonoperative treat-
ment, surgery may be considered after a careful assessment of
clinical findings and imaging studies. The specific pathology dic-
tates the surgical plan. If the patient has adjacent segment steno-
sis without any evidence of instability, a decompressive laminec-
tomy is indicated (Case 63.5). If there is any evidence of
instability, the fusion should be extended as needed. The use of
dynamic stabilization has been described, but there is no good
evidence at this time supporting its use in this setting.
MINIMALLY INVASIVE SURGERY FOR
DEGENERATIVE SPONDYLOLISTHESIS
To minimize the adverse effects of exposure-related muscle
injury, minimally invasive techniques of decompression and
interbody fusion are being performed with increasing fre-
quency. The reported advantages include less soft tissue trauma,
less postoperative pain, and reduced blood loss. The increasing
popularity of minimally invasive surgery in degenerative condi-
tions of the lumbar spine raises the question of whether these
LWBK836_Ch63_p617-632.indd 624
techniques are appropriate in the patient with degenerative
spondylolisthesis who often has bilateral stenosis. Although
performing an interbody fusion through a minimally invasive
approach is relatively straightforward in experienced hands,
the decompression can be challenging if there is significant
bilateral stenosis. There are two approaches to this problem:
one may perform a unilateral decompression on the symptom-
atic side, despite the presence of bilateral lateral recess and/or
nerve root compression on imaging studies. Caution should be
used in deciding to perform a unilateral decompression in the
presence of bilateral stenosis because symptoms may develop on
the contralateral side postoperatively. There are no studies doc-
umenting the efficacy of this approach in long-term follow-up.
The other approach is to perform a bilateral decompression
through a minimally invasive unilateral approach. Favorable
short-term results have been reported with this technique.6
Patients with severe bilateral stenosis are not good candidates
for this approach.
Although the results of the minimally invasive TLIF tech-
nique have been largely favorable, at the time of this writing,
there has only been one comparison study of minimally inva-
sive versus traditional PLIF.24 In this nonrandomized study,
there was no significant difference between the two groups in
the clinical and radiographic results at a minimum of 1 year
follow-up. The minimally invasive group had less blood loss,
postoperative back pain, and shorter recovery time before
ambulation, but surgical times were significantly longer and
there were two cases that required revision surgery due to tech-
nical complications.
The indications for minimally invasive approaches are
expanding, and these techniques are being used in patients
with multilevel disease. At this time, there is no evidence that
long-term outcomes are improved compared with traditional
open approaches, and technical complications are likely to be
more common in the hands of a surgeon without extensive
experience with these techniques. Although these techniques
appear to be promising, spine surgeons attempting these pro-
cedures should honestly assess their experience and skills and
undergo proper training to avoid technical complications. As
the trend toward less invasive approaches continues, well-de-
signed randomized comparison studies are needed to deter-
mine the efficacy of these approaches.
DYNAMIC STABILIZATION
Dynamic stabilization consists of semirigid posterior stabilization
devices that are designed to reduce motion at the instrumented
level to unload the disc and facet joints. The most commonly
used dynamic stabilization system is Dynesys (Zimmer, Inc.,
Warsaw, IN).
The use of dynamic stabilization in degenerative spondylolis-
thesis has been reported to have favorable outcomes, but these
reports are retrospective case series or prospective studies with-
out a comparison group. Given the high level of evidence pro-
vided by the SPORT study supporting decompression and
fusion for this condition,28 the use of semirigid stabilization or
other motion-preserving techniques cannot be justified in the
presence of segmental instability. In the absence of a fusion,
failure of implants or screws remains a concern on long-term
follow-up. Many of these devices are currently under review by
the U.S. Food and Drug Administration, and long-term out-
comes on their efficacy is lacking for degenerative conditions
of the lumbar spine.
8/17/11 10:59:53 AM
 Chapter 63 Adult Degenerative Spondylolisthesis Without Lysis 625

The use of interspinous process devices has also been evalu-
ated in patients with neurogenic claudication and degenerative
spondylolisthesis. The X STOP implant is a titanium alloy
device that is placed between the spinous processes to reduce
the canal and foraminal narrowing that occurs in extension.
Anderson et al performed a randomized study comparing the
use of the X STOP device (St. Francis Medical Technologies,
Alameda, CA) with nonoperative treatment (33 patients) in
patients with neurogenic claudication and degenerative spon-
dylolisthesis.1 At 2-year follow-up, overall clinical success
occurred in 63.4% of X STOP devicetreated patients and only
12.9% of nonoperatively treated patients. This randomized
study showed that the X STOP device is more effective than
nonoperative treatment for this condition and may be a viable
option in elderly patients with significant comorbidities who
are not candidates for a fusion procedure.

CASE 63.1

Figure 63.3 A to E: A 56-year-old woman with bilateral leg spondylolisthesis at L4-5. She underwent decompressive
pain and low back pain. Leg pain/back pain 70/30. She laminectomy at both levels and a posterolateral fusion at
has spinal stenosis at L3-4 and L4-5 and degenerative L4-5. She had an excellent clinical result.

A B

C D E

Figure 63.3. (A) Lateral radiograph showing L4-5 spondylolisthesis. (B) Sagittal magnetic resonance
imaging (MRI) showing degenerative spondylolisthesis. (C) Axial MRI showing stenosis at L4-5. (D) Axial
MRI showing stenosis at L3-4. (E) Lateral radiograph after posterolateral fusion and instrumentation L4-5.

LWBK836_Ch63_p617-632.indd 625 8/17/11 10:59:53 AM

 626 Section VI Spondylolisthesis

CASE 63.2

Figure 63.4 A to E: A 75-year old-man with left leg pain a TLIF (bilateral decompression) and had complete resolu-
worse than low back pain. He has a degenerative spon- tion of leg pain and back pain postoperatively.
dylolisthesis at L4-5 and spinal stenosis. He underwent

A B C

D E

Figure 63.4. (A) Lateral radiograph showing degenerative spondylolisthesis at L4-5. (B) Anteroposterior
radiograph lumbar spine. (C) Sagittal magnetic resonance imaging (MRI) showing stenosis at L4-5. (D) Axial
MRI showing stenosis at L4-5. (E) Lateral radiograph after fusion and instrumentation.

LWBK836_Ch63_p617-632.indd 626 8/17/11 10:59:56 AM

 Chapter 63 Adult Degenerative Spondylolisthesis Without Lysis 627

CASE 63.3

Figure 63.5 A to D: A 62-year-old woman with a 1-year foramen. It is important to decompress the exiting nerve
history of low back pain and left leg radiculopathy. She root in degenerative spondylolisthesis, which is compressed
underwent a TLIF at L4-5. Note the disc bulge compressing between the L4 pedicle and the L4-5 disc (see Fig. 63.2).
the L4 nerve root in the sagittal MR image through the

A B

C D

Figure 63.5. (A) Lateral radiograph showing spondylolisthesis at L4-5. (B) Sagittal magnetic resonance
imaging (MRI) showing disc bulge compressing the L4 nerve root in the foramen. (C) Axial MRI at L4-5
level. (D) Lateral radiograph after TLIF at L4-5.

LWBK836_Ch63_p617-632.indd 627 8/17/11 10:59:57 AM

 628 Section VI Spondylolisthesis

CASE 63.4

Figure 63.6 A to F: A 58-year-old woman with LBP and decompressive laminectomy from L3 to S1 and posterolat-
left worse than right leg pain. She has a degenerative eral fusion and instrumentation from L4-S1. L4-5 and L5-S1
spondylolisthesis at L4-5 and a subtle slip at L5-S1. She levels were fused because of structural instability at both
has spinal stenosis from L3 to L5. She underwent levels.

A B C

D E F

Figure 63.6. (A) Lateral radiograph in extension. (B) Lateral radiograph in flexion. (C) Sagittal magnetic
resonance imaging (MRI). (D) Axial MRI at L3-4 level showing mild stenosis. (E) Axial MRI at L4-5 level
showing stenosis. (F) Axial MRI at L5-S1.

LWBK836_Ch63_p617-632.indd 628 8/17/11 10:59:59 AM

 Chapter 63 Adult Degenerative Spondylolisthesis Without Lysis 629

CASE 63.5

Figure 63.7 A to E: A 55-year-old man who underwent
TLIF for degenerative spondylolisthesis. He had an excel-
lent clinical result with complete resolution of leg and
back pain. Four years later, he developed left leg pain
again, mostly in the buttock and thigh region. He has
developed adjacent segment stenosis. He was treated with a
decompressive laminectomy at L3-4 and had resolution of
his leg pain. We considered extending the fusion, but we
were able to perform a good decompression without creat-
ing instability.

A B

Figure 63.7. (A) Lateral radiograph

showing fusion and instrumentation
L4-5. (B) Anteroposterior radiograph
lumbar spine. (C) Axial magnetic reso-
nance imaging (MRI) at L3-4 level
showing stenosis. (D) Midsagittal MRI.
(continued) C D

LWBK836_Ch63_p617-632.indd 629 8/17/11 11:00:02 AM

 630 Section VI Spondylolisthesis

CASE 63.6

Figure 63.8 A to E: A 78-year-old man with significant low

back pain and bilateral lower extremity claudication. We
performed decompressive laminectomy at L3-S1 and pos-
terolateral fusion with instrumentation at L4-5. He had
relief of leg pain and improvement in his low back pain.

Figure 63.7. (Continued) (E) Sagittal MRI through foramen.

A B C

D E

Figure 63.8. (A) Lateral radiograph showing degenerative spondylolisthesis L4-5. (B) Midsagittal mag-
netic resonance imaging (MRI). (C) Axial MRI at L4-5 showing lateral recess stenosis. (D) Axial MRI at L3-4
showing lateral recess stenosis. (E) Axial MRI at L5-S1 showing lateral recess stenosis.

LWBK836_Ch63_p617-632.indd 630 8/17/11 11:00:04 AM

 Chapter 63 Adult Degenerative Spondylolisthesis Without Lysis 631

CASE 63.7

Figure 63.9 A to F: A 74-year-old woman with longstand-
ing low back pain and 1-year history of bilateral leg pain,
left worse than right. She has a degenerative spondylolis-
thesis at L4-5, which is subtle on supine X-ray and MRI
but is more unstable in the upright flexion/extension
radiographs. This illustrates the importance of upright
flexion/extension films and the danger of relying on
MRI, which can underestimate the degree of instability
due to patients supine position. She also has a caudally
sequestered disc herniation at L3-4. Although L5-S1 is
degenerated, it is probably stable and does not require
fusion. Reasons to fuse this level include the need for a
wide decompression that would render the segment unsta-
ble. This patient did not have stenosis at L5-S1. This patient
underwent a posterolateral instrumented fusion and
laminectomy from L3-L5 with a discectomy performed at
L3-4. L3-4 was fused because it was felt to be at risk of fur-
ther degeneration after discectomy.

A B C

D E F

Figure 63.9. (A) Supine lateral radiograph showing subtle slip at L4-5. (B) Flexion and (C) extension lat-
eral radiographs showing more pronounced instability in upright position. (D) Sagittal magnetic resonance
imaging (MRI) showing subtle slip at L4-5. (E) Axial MRI at L3-4 showing disc herniation. (F) Axial MRI at
L4-5 showing stenosis.

LWBK836_Ch63_p617-632.indd 631 8/17/11 11:00:07 AM

 632 Section VI Spondylolisthesis

without hypermobility on flexion-extension radiographs. J Neurosurg (Spine 3) 2002; 97:

REFERENCES 281286.
15. Lee CK, Langrana NA. Lumbosacral spinal fusion: a biomechanical study. Spine 1984;9:
1. Anderson PA, Tribus CB, Kitchel SH. Treatment of neurogenic claudication by inters-
574581.
pinous decompression: application of the X STOP device in patients with lumbar degen-
16. Lehmann TR, Spratt KF, Tozzi JE. Long-term follow-up of lower lumbar fusion patients.
erative spondylolisthesis. J Neurosurg Spine 2006;4:463471.
Spine 1987;12(2):97104.
2. Bridwell KH, Sedgewick TA, OBrien MF, et al. The role of fusion and instrumentation in
17. Lowe TG, Tehernia AD, OBrien MF, Smith DAB. Unilateral transforaminal posterior lum-
the treatment of degenerative spondylolisthesis with spinal stenosis. J Spinal Disord
bar interbody fusion: indications, technique, and 2-year results. J Spinal Disord Tech
1993;6:461472.
2002;15:3138.
3. Epstein N, Epstein J. Decompression in the surgical management of degenerative spondylolis-
18. Marchetti PG, Bartolozzi P. Classification of spondylolisthesis as a guideline for treatment.
thesis: advantages of a conservative approach in 290 pts. J Spinal Disord 1998;11:116122.
In Bridwell KH, DeWald RL, (eds). The textbook for spinal surgery, 2nd ed. Philadelphia,
4. Fischgrund JS, Mackay M, Herkowitz HN. 1997 Volvo Award Winner in clinical studies:
PA: Lippincott-Raven, 1997:12111254.
degenerative lumbar spondylolisthesis with spinal stenosis: a prospective, randomized
19. Mardjetko SM, Connolly PJ, Shott S. Degenerative lumbar spondylolisthesis: a meta-analysis
study comparing decompressive laminectomy and arthrodesis with and without spinal
of literature 19701993. Spine 1994;19(20 Suppl):S2256S2265.
instrumentation. Spine 1997;22:28072812.
20. Matsunaga S, Ijiri K, Hayashi K. Nonsurgically managed patients with degenerative spon-
5. Ghogawala Z, Benzel EC, Amin-Hanjani S, et al. Prospective outcomes evaluation after
dylolisthesis: a 10 to 18 year follow-up study. J Neurosurg (Spine 2) 2000;93:194198.
decompression with or without instrumented fusion for lumbar stenosis and degenerative
21. Matsunaga S, Sakou T, Morizono Y, et al. Natural history of degenerative spondylolisthesis:
Grade 1 spondylolisthesis. J Neurosurg (Spine 1) 2004;3:267272.
pathogenesis and natural course of the slippage. Spine 1990;15:12041210.
6. Guiot BH, Khoo LT, Fessler RG. A minimally invasive technique for decompression of the
22. Nork SE, Hu SS, Workman KL, et al. Patient outcomes after decompression and instru-
lumbar spine. Spine 2002;27:432438.
mented posterior spinal fusion for degenerative spondylolisthesis. Spine 1999;24:
7. Herkowitz HN, Kurz LT. Degenerative lumbar spondylolisthesis with spinal stenosis: a pro-
561569.
spective study comparing decompression with decompression and intertransverse process
23. Park P, Garton HJ, Gala VC. Adjacent segment disease after lumbar or lumbosacral fusion:
arthrodesis. J Bone Joint Surg Am 1991;73A:802808.
review of the literature. Spine 2004;29(17):19381944.
8. Herron LD, Trippi AC. L45 degenerative spondylolisthesis. The results of treatment by
24. Park Y, Ha JW. Comparison of one-level posterior lumbar interbody fusion performed with
decompressive laminectomy without fusion. Spine 1989;14:534538.
a minimally invasive approach or a traditional open approach. Spine 2007;32:537543.
9. Hsieh PC, Koski TR, OShaughnessy BA. Anterior lumbar interbody fusion in comparison
25. Postacchini F, Cinotti G, Perugia D. Degenerative lumbar spondylolisthesis II. Surgical
with transforaminal lumbar interbody fusion: implications for the restoration of foraminal
Treatment. Ital J Orthop Traumatol 1991;17:467477.
height, local disc angle, lumbar lordosis, and sagittal balance. J Neurosurg Spine
26. Shono Y, Kaneda K, Abumi K, et al. Stability of posterior spinal instrumentation and its
2007;7(4):379386.
effects on adjacent motion segments in the lumbosacral spine. Spine 1998;23(14):
10. Kim KT, Lee SH, Lee YH. Clinical outcomes of 3 fusion methods through the posterior
15501558.
approach in the lumbar spine. Spine 2006;31:13511357.
27. Sudo H, Oda I, Abumi K. In vitro biomechanical effects of reconstruction on adjacent
11. Kimura I, Shingu H, Murata M, et al. Lumbar posterolateral fusion alone or with trans-
motion segment: comparison of aligned/kyphotic posterolateral fusion with aligned pos-
pedicular instrumentation in L4-L5 degenerative spondylolisthesis. J Spinal Disord
terior lumbar interbody fusion/posterolateral fusion. J Neurosurg 2003;99(2 Suppl):
2001;14:301310.
221228.
12. Kleeman TJ, Hiscoe AC, Berg EE. Patient outcomes after minimally destabilizing lumbar
28. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical versus nonsurgical treatment for lum-
stenosis decompression: the Port-Hole technique. Spine 2000;25(7):865870.
bar degenerative spondylolisthesis. N Engl J Med 2007;356(22):22572270.
13. Kornblum MB, Fischgrund JS, Herkowitz HN, et al. Degenerative lumbar spondylolisthesis
29. Wiltse LL, Newman PH, Macnab I. Classification of spondylolysis and spondylolisthesis.
with spinal stenosis. A prospective long-term study comparing fusion and pseudarthrosis.
Clin Orthop Relat Res 1976;117:2329.
Spine 2004;29:726734.
30. Zdeblick TA. A prospective, randomized study of lumbar fusion: preliminary results. Spine
14. Kristof RA, Aliashkevich AF, Schuster M, et al. Degenerative lumbar spondylolisthesis-
1993;18:983991.
induced radicular compression: nonfusion-related decompression in selected patients

LWBK836_Ch63_p617-632.indd 632 8/17/11 11:00:10 AM