Management of Spondylolisthesis L4-L5 with Radiculopathy

Initial Management and Surgical Indications

Surgical decompression with fusion is the recommended treatment for symptomatic L4-L5 spondylolisthesis with radiculopathy after failure of conservative management, as recommended by the American Association of Neurological Surgeons 1, 2
Persistent or progressive symptoms after 6 weeks of optimal conservative management indicate the need for surgical intervention, according to the American College of Radiology 3
Significant neurological symptoms, including radiculopathy, and functional limitations affecting quality of life are indications for surgical intervention, as suggested by the American Association of Neurological Surgeons 1, 2

Decompression with fusion is superior to decompression alone for spondylolisthesis with radiculopathy, with a strong recommendation from the American Association of Neurological Surgeons 1, 4
Posterolateral fusion (PLF) following decompression is the standard approach, as recommended by the American Association of Neurological Surgeons 2
Pedicle screw fixation should be considered in cases with kyphosis at the level of spondylolisthesis or evidence of instability on dynamic imaging, according to the American Association of Neurological Surgeons 4

MRI is the initial imaging modality of choice for patients with radiculopathy who have failed conservative therapy, as recommended by the American College of Radiology 3
Upright radiographs with flexion-extension views are essential to identify segmental motion and instability, according to the American College of Radiology 3
CT myelography can be useful when MRI is contraindicated or to better assess bony anatomy, as suggested by the American College of Radiology 3

The SPORT studies provide strong evidence supporting surgical intervention for spondylolisthesis with stenosis, demonstrating superior outcomes in all clinical measures for at least 4 years following surgical treatment compared to non-operative management, with a high level of evidence from the American Association of Neurological Surgeons 1, 2
Decompression and fusion result in higher satisfaction rates and improved functional outcomes, with a moderate level of evidence from the American Association of Neurological Surgeons 2

Potential complications of surgical intervention include nerve root injury, dural tear, or infection, with a low level of evidence from Praxis Medical Insights 5
Failure of fusion or hardware complications are potential risks, with a moderate level of evidence from the American Association of Neurological Surgeons 4

Regular radiographic assessment is necessary to evaluate fusion status, with a moderate level of evidence from the American Association of Neurological Surgeons 6
Monitoring for adjacent segment disease is essential in long-term follow-up, with a moderate level of evidence from the American Association of Neurological Surgeons 2