Diagnosis and Treatment of Spondylolisthesis

Clinical Presentation and Symptoms

Spondylolisthesis typically presents with low back pain, which may be accompanied by radiculopathy or neurogenic claudication, according to the American College of Radiology 1
Radicular symptoms following dermatomal patterns are common in spondylolisthesis, as noted by the American College of Radiology 1
Neurogenic claudication in cases with spinal stenosis is a symptom of spondylolisthesis, as reported by the Journal of Neurosurgery 2

The American College of Radiology recommends standing anteroposterior and lateral radiographs of the lumbar spine as the first imaging study for suspected spondylolisthesis 4, 5
Flexion-extension radiographs provide valuable functional information about segmental motion, which is essential in evaluating stability and surgical planning for spondylolisthesis, according to the American College of Radiology 1
MRI of the lumbar spine is the next appropriate step when radiographs are positive for spondylolisthesis or when symptoms persist despite negative radiographs, as recommended by the American College of Radiology 1, 6
MRI provides excellent soft-tissue contrast to evaluate neural compression, disc degeneration, and facet joint arthropathy, as noted by the American College of Radiology 1, 7

Disc herniation typically presents with more radicular symptoms and less mechanical back pain, according to the American College of Radiology 1
Facet arthropathy pain usually worsens with extension and rotation rather than flexion, as reported by the American College of Radiology 9
Inflammatory spondyloarthropathies should be considered when back pain has inflammatory features, such as morning stiffness and improvement with activity, as noted by the American College of Radiology 9
Spinal infection should be suspected with fever, elevated inflammatory markers, and risk factors, according to the European Journal of Nuclear Medicine and Molecular Imaging 10

The American College of Radiology and the Journal of Neurosurgery recommend decompression with fusion for symptomatic stenosis with degenerative spondylolisthesis, as it provides superior outcomes compared to non-surgical treatment 2, 11
Posterolateral fusion with pedicle screw fixation is the standard approach for spondylolisthesis with instability, as reported by the Journal of Neurosurgery and the American College of Radiology 2, 11
Surgical intervention has been shown to have superior outcomes compared to non-surgical treatment for at least 4 years of follow-up, according to the Journal of Neurosurgery and the American College of Radiology 2, 11

Patients treated non-surgically should be monitored for development of neurological deficits, as recommended by Praxis Medical Insights 3
Post-surgical follow-up should assess fusion status, as noted by the Journal of Neurosurgery 2
Hardware complications should be monitored post-surgically, according to Praxis Medical Insights 11

Failing to obtain standing radiographs is a common pitfall in the evaluation of spondylolisthesis, as noted by the American College of Radiology 1, 4
Relying solely on MRI without functional radiographs can miss potential instability, according to the American College of Radiology 1
Delaying surgical intervention in patients with progressive neurological deficits is a pitfall to avoid, as recommended by Praxis Medical Insights 3