Spondylolisthesis

Original Editors - Margo De Mesmaeker

Top Contributors - Maëlle Cormond, Simisola Ajeyalemi, Evi Peeters, Margo De Mesmaeker, Kim Jackson, Admin, Chrysolite Jyothi Kommu, Kenneth de Becker, Shaimaa Eldib, Lucinda hampton, Mike Myracle, Rachael Lowe, Evan Thomas, Aminat Abolade, Mariam Hashem, Carlos De Coster, Johnathan Fahrner, Camille Linussio, Shreya Pavaskar, Scott Buxton, Claire Knott, Rucha Gadgil, Laura Ritchie, Jess Bell and Kirenga Bamurange Liliane

Definition / Description

The term spondylolisthesis is derived from the Greek words spondylo = vertebra, and olisthesis = translation.[52](LE: 5) Spondylolisthesis is defined as a translation of one vertebra over the adjacent caudal vertebra. This can be a translation in the anterior (anterolisthesis) or posterior direction (retrolysthesis) or, in more serious cases, anterior-caudal direction.[1](LE: 2A) [2](LE: 1A) It is classified on the basis of etiology into the following six types by Wiltse: Dysplastic (congenital), isthmic, degenerative, traumatic, pathologic and iatrogenic spondylolisthesis.[1](LE: 2A) [3]
[57](LE: 2A)

Clinically Relevant Anatomy

The main anatomical structure involved is the fractured pars interarticularis of the lumbar vertebrae  (LE: 3A). In addition, ligamentous structures, including the iliolumbar ligament, between L5 and the sacrum, are stronger than those between L4 and L5, by which the vertebral slip commonly develops in L4  (LE: 3B).

Isthmic or spondylolytic spondylolisthesis (type II) appears mainly at the lumbosacral level. (L5-S1)  (LE: 2B). It is characterized by high lordosis angles and lordotic wedging of the affected vertebra (L5) and very high L4-5 intervertebral disc wedging  (LE: 3B)  (LE: 2B).

Degenerative spondylolisthesis (type III) appears mainly at the L4-5 level and is characterized by a significant constriction of the cauda equina, combined with a diminished cross-sectional area of the vertebral canal, thickening and buckling of the ligamentum flavum and hypertrophy of adjacent facet joints  (LE: 2B).

Figure 1: Scottie dog  (LE :1B).

Epidemiology / Etiology

One of the most commonly used classification systems to convey the etiology of a spondylolisthesis is the Wiltse Classification:

 
• Type 1 : Congenital spondylolisthesis
An elongation of the pars interarticularis can be seen in congenital spondylolisthesis, in which the pars lesion is due to a congenital anomaly of the L5-S1 facet articulation. As the slip progresses, the pars elongates in response to the deformity. Therefore, with an elongated pars, it is important to evaluate the lumbosacral facets to properly classify the lesion.[57](LE: 2A)
The symptoms usually develop during the adolescent growth period.[10](LE: 5)

• Type 2: Isthmic spondylolisthesis
Isthmic spondylolisthesis, or spondylolisthesis due to a lesion of the pars interarticularis, is a common source of pain and disability in both pediatric and adult population.
The basic lesion in isthmic spondylolisthesis is in the pars interarticularis and mainly appears at the lumbosacral level (L5-S1).[6](LE: 2B) It is characterized by high lordosis angles and lordotic wedging of the affected vertebra (L5) and very high L4-5 intervertebral disc wedging.[7](LE: 3B) [8](LE: 2B)

 
Wiltse et al. divided this category into three subtypes: lytic, elongated and acute fracture.
The first subtype, the lytic lesion of the pars, is the most common cause of spondylolisthesis and is termed spondylolysis. This defect is present in 6% of the population by young adulthood.
The second subtype of isthmic spondylolisthesis, elongation of the pars interarticularis, is thought to be due to repetitive microfractures with subsequent healing in an elongated position. Elongation of the pars can also be seen in congenital spondylolisthesis.
Finally, the third subtype is an acute fracture of the pars, resulting from a single traumatic episode. Wiltse et al. suggested that this type of isthmic spondylolisthesis could also be classified as traumatic spondyloslisthesis.[57](LE: 2A)
Isthmic spondylosithesis is typically considered as a pediatric condition.[20](LE: 1A) But Saraste (1987) demonstrated that the onset of symptoms tends to occur after childhood, with a mean age at presentation of 20 years.[21](LE: 2B)

• Type 3 : Degenerative spondylolisthesis
Degenerative spondylolisthesis is most common in adults.[54](LE: 2A)
In this type the L4–L5 vertebral space is affected 6 to 9 times more commonly than other spinal levels.[22](LE: 2B) [10](LE: 5) It is characterized by a significant constriction of the cauda equina, combined with a diminished cross-sectional area of the vertebral canal, thickening and buckling of the ligamentum flavum and hypertrophy of adjacent facet joints.[6](LE: 2B) It is also a common condition in the elderly (>50 years).

The main causes are: [23](LE: 3A) [24](LE: 5) [25](LE: 1A)
• Disc degeneration;
• Facet joint arthrosis;
• Malfunction of the ligamentous stabilizing component;
• Ineffectual muscular stabilization.
Degenerative spondylolisthesis is believed to result from chronic intersegmental instability. Degenerative changes to both the facet joints and the intervertebral disk cause the slip. Sagittal orientation of the facet joints and facet tropism also have been related to the development of degenerative spondylolisthesis. [57](LE: 2A)

• Type 4: Traumatic spondylolisthesis
Traumatic spondylolisthesis is caused by a fracture in a region other than the pars. This fracture leads to slippage of the vertebrae.[57](LE: 2A)

• Type 5: pathological spondylolisthesis
Pathological spondylolisthesis is due to generalized or localized musculoskeletal processes affecting the posterior elements and causing instability.[57](LE: 2A)
Diffuse or local disease compromises the usual structure integrity that prevents slippage.[58](LE: 3B)

• Type 6: iatrogenic spondylolisthesis
Iatrogenic spondylolisthesis results from excessive removal of the posterior elements after laminectomy.[57](LE: 2A)

The incidence of spondylolisthesis varies considerably depending on ethnicity, sex, and sports activity.[10](LE: 5) Several epidemiological studies have revealed that the incidence of symptomatic listhesis in Caucasian populations varies from 4 to 6% [11](LE: 2A) [12](LE: 2A), but rises as high as 26% in secluded Eskimo populations [13](LE: 2A) and varies from 19 to 69% among first-degree relatives of the affected patients.[14](LE: 2A)
Depending on the studies conducted, this percentage can vary. [15](LE:2B) [16](LE: 2B) [17](LE: 2B) [18](LE: 2B) [19](LE: 2B)

Potential risk factors are: [26](LE: 3A)
• Increasing age;
• Female sex;
• Pregnancies;
• African-American ethnicity;
• Generalized joint laxity
• Anatomical predisposition (sagitally oriented facet joints, hyperlordosis, high pelvic incidence)

Characteristics / Clinical Presentation

Figure 2: Highest stress during various lumbar motions is found at the pars interarticularis, as shown in a threedimensional finite element moedel  (LE: 2B)

Symptoms and findings in spondylolisthesis are: [68](LE: 2A)

•  Pain
•  Trophic changes
•  Atrophy of the muscles
•  Tense hamstrings
•  Disturbance in patterns
•  Diminished ROM (spine)
•  Disturbances in coördination and balance
•  Neurological symptoms (possible evolution towards cauda equine syndrome)
•  Dull pain, typically situated in the lumbosacral region after exercise, especially with an extension of the lumbar spine
  
  

Patients usually report that their symptoms vary as a function of mechanical loads (such as in going from supine to erect position) and pain frequently worsens over the course of the day (figure 3). Radiation into the posterolateral thighs is also common and is independent of neurologic signs and symptoms. The pain could be diffuse in the lower extremities, involving the L5 and/or L4 roots unilaterally or bilaterally  (LE: 5).

In addition to these findings, each type of spondylolythesis has its own characteristics

→ Ankylosing Spondilytis

→ Enteropathic Spondylitis

→ Lumbosacral Spondylolys

Spondylolisthesis can occur with other disorders and seems to have a link with some of them:

• Spina bifida occulata  (LE: 2B)  (LE: 2C)  (LE: 3B);

Several studies support a positive association between spina bifida occulta and spondylolysthesis  (LE: 2A). This high association may not be due to mechanical factors but to genetic factors  (LE: 2C).

• Cerebral palsy  (LE: 2B);

A number of studies proved the association between cerebral palsy and spondylolysthesis, certainly in athetoid cerebral palsy (60%)  (LE:2B).

• Scheuermann’s disease  (LE: 2B)  (LE: 2B);

Ogilvie and Sherman reported a 50% incidence of spondylolysthesis in 18 patients with Scheuermann’s disease  (LE: 2B). Greene et al. found spondylolysthesis (grade I or II) at L5-S1 in 32% of patients with Scheuermann’s disease (LE: 2B).

• Scoliosis  (LE: 2A).

Fisk et al. reported that the incidence in 539 patients with ideopathic scoliosis was 6.2%, which corresponded to that found in the general population  (LE: 2B). But the relation between scoliosis and spondylolysthesis has not been clarified  (LE:2A).

•  Spinal stenosis [53](LE: 2A);

Spinal stenosis and degenerative spondylolisthesis share many symptoms and the same treatment. Bone mineral density (BMD) has been suggested to play a role. Andersen T. et al. reported that 39% of degenerative spondylolisthesis patients were classified as osteoporotic and further 30% osteopenic compared to only 9% of spinal stenosis patients being osteoporotic and 30% osteopenic. Which means that BMD is likely to play a role in the development of the degenerative spondylolisthesis.

Differential Diagnosis

• Spondylolysis  (LE: 1A)  (LE: 4)
• Metastatic disease  (LE: 2B)
• Low back pain  (LE: 1C)
• Osteoarthritis  (LE: 1C)  http://www.physio-pedia.com/Osteoarthritis
• Neuroforaminal stenosis  (LE: 1C)
• Spinal Stenosis  (LE: 1C)
  

Diagnostic Procedures / Examination

History
Specific questions should be asked to the patient referring to:

•  Pain [38](LE: 1C)
•  Location
•  Severity
•  Duration
•  Quality (for example: tingling, burning,.. sensations)
•  Exacerbating factors
•  Alleviating factors
•  Leisure activities [38](LE: 1C)
•  Occupational risks [38](LE: 1C)
•  Pain changes throughout day: difference morning compared to evening/night?

Imaging
Radiological assessments are required in order to make the diagnosis clear and to determine the grade and prognosis of spondylolisthesis.[70]( LE:2B)
Most commonly used clinical imaging is X-ray, CT and MRI. [36](LE: 1A)

•  X-ray

Overall X-ray of the spine and lumbosacral X-ray are seen as the golden standard for diagnosis.[38](LE: 1C) There are multiple views used with the most common one being the anteroposterior, lateral and oblique views.[36](LE: 1A) [9](LE: 1B) [6](LE: 2B) Multiple characteristics can be seen, such as the degree of the slip or the slip angle. The most prominent sign remains the defect of the pars interarticularis, or more commonly named the broken collar or neck of the “Scottie Dog”.[9](LE: 1B)

•  CT and MRI

Advanced imaging techniques like MRI and CT have to be used when neurological symptoms are present, and when surgical intervention is indicated.[70](LE:2B) CT and MRI, which give an accurate localization and a better illustration of the lesion [35](LE: 1A), are taken when one of the following signs are present: [6](LE: 2B)

•  Significant and progressing neurologic claudication [6](LE: 2B) [38](LE: 1C)
•  Radiculopathies and the clinical suspicion that another condition may be causative [6](LE: 2B) [38](LE: 1C)
•  Bladder or bowel complaints [6](LE: 2B)
•  Metastatic disease [38](LE: 1C)

And are used for one of the following reasons:

•  Evaluating an atypical presentation including pre-lysis [9](LE: 1B)
•  Determining the condition of the intervertebral disc [36](LE: 1A)
•  Evaluating vertebral slipping and possible neural element compression [6](LE: 2B) [38](LE: 1C)

CT and MRI give the best visualization of bone morphology and are therefore, most often used to check the alignment of the facet joints and their degenerative changes.[36](LE: 1A) [6](LE: 2B) [38](LE: 1C) Images resulting from CT and MRI are the most sensitive and specific when a pars fracture is present.[9](LE: 1B)
Myelography can be used together with CT, but nowadays MRI is used instead.[6](LE: 2B)

Outcome Measures

Oswestry Disability Index

Medical Management

General  (LE: 2B),  (LE: 2B)

• Initially resting and avoiding movements like lifting, bending and sports.
• Analgesics and NSAIDs reduce musculoskeletal pain and have an anti-inflammatory effect on nerve root and joint irritation.
• Epidural steroid injections can be used to relieve low back pain, lower extremity pain related to radiculopathy and neurogenic claudication.
• A brace may be useful to decrease segmental spinal instability and pain.  (LE: 3B)

Surgery

Patients with chronic and disabling symptoms, who fail to respond to conservative management may be referred for surgery.[63](LE: 1B)
When the condition of spinal instability is very severe, a surgical intervention may be necessary to attach the vertebras together.[63](LE: 1B) It can help the patient to reduce pain, improve spinal function and increase the quality of life. The goal of surgery is to stabilize the segment with listhesis, decompress the neural elements, reconstruction of the disc space height and restoration of normal sagittal alignment.[1](LE: 2A) [41](LE: 2C) The grade of listhesis can be reduced to some extent, but complete reduction is rarely achieved.[41](LE:2C) There is a wide variety of complications, such as neurological complications, vascular injury, instrument failure, and infections.[1](LE: 2A) [6](LE: 3B) [39](LE: 2B)

Only perform a surgical intervention after a careful analysis of indications and outcomes.[63](LE: 1B)
When evaluating a patient, many factors, such as age, degree of slip and risk of slip progression, must be considered. Also a thorough evaluation of social and physiological factors should be undertaken. Therefore each patient's treatment program should be individualized to achieve optimal outcome.[1](LE: 2A) [41](LE: 2C)

Indications [6](LE: 2B) [1](LE: 2A) [42](LE: 1A)

• Neurologic signs / neurogenic claudication / radiculopathy (unresponsive to conservative measures)
• Myelopathy
• High-grade slip (>50%)
• Type 1 (congenital) and 2 (isthmic) slips with evidence of instability, progression of listhesis, or lack of response to conservative measures
• Type 3 (degenerative) listhesis with gross instability and incapacitating pain
• Bladder or bowel symptoms (especially in type 3)
• Traumatic spondylolisthesis
• Iatrogenic spondylolisthesis
• Postural deformity and gait abnormality

Contra-indications [1](LE: 2A)

• Poor medical health
• High operative risk (higher risk than potential benefits)
• High risk of hemorrhage: Anticoagulation with warfarin, or antiplatelet therapy
• Smoking

There are several different options for surgical treatment; one of them is fusion (e.g. posterolateral fusion). The aim of fusion is to reduce pain by reducing the motion of the segment. Other treatment options include decompression (Gill laminectomy), supplemental instrumentation and supplemental anterior column support. Controversies exist about the effectiveness of these treatment options that can be used separately or in any combination.[6](LE: 3B) [39](LE: 1A)
A surgical intervention has better results than nonoperative treatment in case of neurological symptoms and for treating pain and functional limitation.[6](LE: 1B) [42](LE: 1A) [40](LE: 2B) [58](LE: 2A) A patient can return to their activity after 6-12 months after surgery depending on the sport. Athletes may return when they have normal strength and range-of-motion, and no pain with sport-specific activity. [71](LE 2B)

Physical Therapy Management

Spondylolisthesis should be treated first with conservative therapy, which includes physical therapy, rest, medication and braces.[43](LE: 3A) [70](LE 2B) Non-operative treatment should be the initial course of action in most cases of degenerative spondylolisthesis and symptomatic isthmic spondylolisthesis, with or without neurologic symptoms. [6](LE: 3A) [70](LE 2B) Children or young adults with a high-grade dysplastic or isthmic spondylolisthesis or adults with any type of spondylolisthesis, who do not respond to non-operative care, should consider surgery.
Traumatic spondylolisthesis can be treated successfully using conservative methods, but most authors suggested it would result in posttraumatic translational instability or chronic low back pain.[44](LE: 3A) Exercises should be done on a daily basis.[6](LE: 2B)

•  Exercise therapy

There is strong evidence for exercise therapy, which consists of strengthening exercises of the deep abdominal musculature.[46](LE: 1B) [45](LE: 1A). In addition, isometric and isotonic exercises may be beneficial for strengthening of the main muscle groups of the trunk, which stabilize the spine. These techniques may also play a role in pain reduction.[46](LE: 1B) [45](LE: 1A) [47](LE: 1B)
In order to improve the patient’s mobility, physical therapy includes stretching exercises of the hamstrings, hip flexors and lumbar paraspinal muscles.[46](LE: 1B) [45](LE: 1A)

Furthermore endurance training is effective for chronic low back pain.[45](LE: 1A) [72](LE: 2A) The objective of stretching and strengthening is to decrease the extension forces on the lumbar spine, due to agonist muscle tightness, antagonist weakness, or both, which may result in decreased lumbar lordosis.[46](LE: 1B) [45](LE: 1A) Rehabilitation programs should be designed to improve muscle balance rather than muscle strength alone.[69](LE: 2B)

There is evidence that suggests that specific stabilization exercises and core stability exercises can be useful in reducing pain and disability in chronic low back pain in patient with spondylolisthesis.[59](LE: 1A) [66](LE: 2B) [68](LE: 2A)
When using core stability exercises a therapist can use different modalities: [68](LE: 2B)

• Movements in closed-chain-kinetics
• Renewing of the motion-pattern
• Antilordotic movement patterns of the spine
• Elastic band exercises in the lying position
• Gait training
• Brace-gymnastics
• Stretching exercises
• Sensomotoric training on unstable devices
• Functional electric stimulation
• Walking in all variations
• Underwater therapy
• Balance training
• Coordinative skills
  
  

Exercises should be done on a daily basis  (LE: 2B).

Figure 3: Strengthening of the deep abdominal muscles.
Alternating legs, with leg extension while exhaling, maintaining contraction of transverse abdominis, paravertebral and pelvic floor muscles  (LE: 1B).

Figure 4: Horizontal side support exercise for core stability  (LE: 1B).

Figure 5: Stretching of the erector spine muscles.
Flexing of the hip, toward the chest  (LE: 1B).

• Lumbosacral braces or corset

In healthy subjects it has been found that the lumbosacral brace can improve the sitting position of the patient. The fact that there was wear of the brace, indicates that the brace has an important function in the sitting position.[64](LE: 2B) Lumbar supports also reduce the numbers of days when low back pain occurs.[65](LE: 1B) According to Prateepavanich et al., a lumbosacral corset can be used to improve walking distance and to reduce pain in daily activities [51](LE: 2B), but it does not reduce the shift of the vertebra.[6](LE:2B) It is a good aid during the painful periods but should be discontinued when the patients' complaints are reduced.

•  Posture and lifting techniques

Special attention has to be given to posture and proper lifting techniques [48](LE: 3A), wherein the physiotherapist has an important educational role.[46](LE: 1B) [45](LE: 1A) Lifting techniques is effective for chronic low back pain.[45](LE: 1A) [72](LE: 2A)

•  Management of catastrophising and kinesiophobia

Physical therapy treatment in combination with management of catastrophising and kinesiophobia gave good results. The disability, pain, dysfunctional thoughts were significant reduced.[63](LE: 1B)

•  Alternative cardiovascular exercise

Athletes with spondylolysis and first-degree spondylolisthesis can take part in all sports activities. However, attention should be given to those kinds of sport where recurring trauma resulting from repeated flexion, hyperextension and twisting is usually undertaken (e.g. gymnastics, aerobics, swimming in the dolphin technique). Athletes with a grade 2, 3 or 4 can also participate in all the sport activities but have to do this with a special and individually adapted directives.[68](LE:2A)

Sports that certainly can be practiced are walking, swimming and cross-training. Although these activities will not improve the shift, these sports are a good alternative for cardiovascular exercises.[6](LE:2B) Impact sports like running should not be done in order to avoid wear. The adolescent athlete or manual laborer should avoid hyperextension and/or contact sports.[48](LE: 3A) Bicycling is also a good cardiovascular exercise, because it promotes spine flexion.

Recent Related Research (from Pubmed)

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References

1. http://emedicine.medscape.com/article/1266860-overview: Amir Vokshoor et al., Spondylolisthesis, Spondylolysis, and Spondylosis. Medscape, updated Sep 10, 2014, Consulted on Oct 20, 2014 (Level of evidence 2A)
2. Tebet, M.A., Currents concepts on the sagittal balance and classification of spondylolysis and spondylolisthesis. Revista Brasileira de Ortopedia, 2014, 49 (1), 3-12. (Level of evidence 1A)
3. Youtube. (2011). Spondylolisthesis - DePuy Videos. Consulted on Nov. 22, 2014, on https://www.youtube.com/watch?v=DlJM2kLGwUI (last accessed 13/10/2014)
4. Garet M. et al., Nonoperative treatment in lumbar spondylolysis and spondylolisthesis: a systematic review, Sports Health, 2013 May; 5(3):225-32 (Level of evidence 3A)
5. Funao H. et al., Comparative study of spinopelvic sagittal alignment between patients with and without degenerative spondylolisthesis, Eur Spine J, 2012; 21:2181-2187 (Level of evidence 3B)
6. Kalichman L. et al, Diagnosis and conservative management of degenerative lumbar spondylolisthesis, Eur Spine J, 2008; 17:327-335 (Level of evidence 2B)
7. Been E. et al, Geometry of the vertebral bodies and the intervertebral discs in lumbar segments adjacent to spondylolysis and spondylolisthesis: pilot study, Eur Spine J, 2011; 20:1159-1165 (Level of evidence 3B)
8. Labelle H. et al., Spino-pelvic alignment after surgical correction for developmental spondylolisthesis, Eur. Spine J, 2008; 17:1170-1176 (Level of evidence 2B)
9. Foreman P. et al, L5 spondylolysis/spondylolisthesis: a comprehensive review with an anatomic focus, Childs Nerv Syst. 2013;29(2):209-16 (Level of evidence 1B)
10. Frymoyer, J.W., Degenerative spondylolisthesis: diagnosis and treatment. Journal of the American Academy of Orthaedic Surgeons, 1994, 2, 9–15. (Level of evidence: 5)
11. McTimoney, C.A. et al, Current evaluation and management of spondylolysis and spondylolisthesis. Current Sports Medicine Reports, 2003, 2, (1), 41–46. (Level of evdidence: 2A)
12. Taillard, W.F., Etiology of spondylolisthesis. Clinical Orthopaedics and Related Research, 1976, 117, 30–39. (Level of evidence: 2A)
13. Stewart, T., The age incidence of neural arch defects in Alaskan natives, considered from the standpoint of etiology. The American Journal of Bone and Joint Surgery, 1953, 35, 937–950. (Level of evidence: 2A)
14. Lonstein, J.E., Spondylolisthesis in children Cause, natural history, and management. Spine, 1999, 24, (24), 2640–2648. (Level of evidence: 2A)
15. Sonne-Holm, S. et al, Lumbar spondylolysis: a life long dynamic condition? A cross sectional survey of 4,151 adults. European Spine Journal, 2007, 16, 821-828. (Level of evidence: 2B)
16. Amato, M. et al, Spondylolysis of the lumbar spine: demonstration of defects and laminal fragmentation. Radiology, 1984, 153, 627-629. (Level of evidence: 2B)
17. Weil, Y. et al, Correlation between pre-employment screening X-ray finding of spondylolysis and sickness absenteeism due to low back pain among policemen of the Israeli police force. Spine (Phila Pa 1976), 2004, 29, 2168-72. (Level of evidence: 2B)
18. Kalichman, L. et al, Spondylolysis and spondylolisthesis: prevalence and association with low back pain in the adult community-based population. Spine (Phila Pa 1976), 2009, 34, 199-205. (Level of evidence: 2B)
19. Belfi, L.M. et al, Computed tomography evaluation of spondylolysis and spondylolisthesis in asymptomatic patients. Spine (Phila Pa 1976), 2006, 31, E907-10. (Level of evidence: 2B)
20. Steven, S.A. et al, (20mc10). Contemporary management of isthmic spondylolisthesis: pediatric and adult. The Spine Journal, 10, 530-543. (Level of evidence: 1A)
21. Saraste, H., Long-term clinical, radiological follow-up of spondylolysis and spondylolisthesis. The Journal of Pediatric Orthophedy, 1987, 7, 631–8. (Level of evidence: 2B)
22. Fitzgerald, J. et al, Degenerative spondylolisthesis. Journal of Bone and Joint Surgery, 1976, 58, 184–192. (Level of evidence: 2B)
23. Sheng-Dan, J. et al, Degenerative cervical spondylolisthesis: a systematic review. International Orthopaedics (SICOT), 2011, 35, 869-875. (Level of evidence: 3A)
24. Vibert, B.T. et al, Treatment of instability and spondylolisthesis: surgical versus nonsurgical treatment. Clinical Orthopaedics and Related Research, 2006, 443, 222–227. (Level of evidence: 5)
25. Sengupta, D.K. et al, Degenerative spondylolisthesis: review of current trends and controversies. Spine, 2005, 30(Suppl), S71–S81. (Level of evidence: 1A)
26. N.J. Rosenberg. Degenerative spondylolisthesis. Predisposing factors. The journal of Bone and Joint Surgery (1975) 57:467-474. (level of evidence 1C)
27. Mays, S., Spondylolysis, spondylolisthesis, and lumbo-sacral morphology in a medieval English skeletal population. American Journal of Physical Anthropolgy, 2006, 131, 352–62. (Level of evidence: 2B)
28. Frymoyer, J.W.,Degenerative spondylolisthesis. In: Andersson GBJ, McNeill TW (eds) Lumbar spinal stenosis. Mosby Year Book, St Louis, 1992 (Level of Evidence: 5)
29. Sairyo, K. et al, Biomechanical comparison of lumbar spine with or without spina bifida occulta: a finite element analysis. Spinal Cord,2006, 44, 440–4. (Level of evidence: 2C)
30. Burkus, J.K., Unilateral spondylolysis associated with spina bifida occulta and nerve root compression. Spine (Phila Pa 1976), 1990, 15, 555–9. (Level of evidence: 3B)
31. Toshinori, S. et al, Incidence and etiology of lumbar spondylolysis: review of the literature. Journal of Orthopaedic Science, 2010, 15, 281-288. (Level of evidence: 2A)
32. Sakai, T. et al, Lumbar spinal disorders in patients with athetoid cerebral palsy: a clinical and biomechanical study. Spine (Phila Pa 1976), 2006, 31, E66–70. (Level of evidence: 2B)
33. Ogilvie, J.W. et al, Spondylolysis in Scheuermann’s disease. Spine (Phila Pa 1976), 1987, 12, 251–3. (Level of evidence: 2B)
34. Greene, T.L. et al, Back pain and vertebral changes simulating Scheuermann’s disease. Journal of Pediatrics Orthopedics, 1985, 5, 1–7. (Level of evidence: 2B)
35. Fisk JR et al, Scoliosis, spondylolysis, and spondylolisthesis: their relationship as reviewed in 539 patients. Spine (Phila Pa 1976) 1978;3:234–45. (Level of evidence 2B)
36. Tsirikos AI et al, Spondylolysis and spondylolisthesis in children and adolescents. J Bone Joint Surg Br. 2010 Jun;92(6):751-9. doi: 10.1302/0301-620X.92B6.23014 (Level of evidence 1A)
37. Nissenbaum J. et al, Differential diagnosis of spondylolysis in a patient with chronic low back pain. J Orthop Sports Phys Ther. 2005 May;35(5):319-26. (Level of evidence 4)
38. Metzger R. et al, Spondylolysis and spondylolisthesis: what the primary care provider should know. J Am Assoc Nurse Pract. 2014 Jan;26(1):5-12. doi: 10.1002/2327-6924.12083. (Level of evidence 1C)
39. Phalen GS. et al, Spondylolisthesis and tight hamstrings. J Bone Joint Surg, 1961, 43:505–512 (Level of evidence 1B)
40. James N. Weinstein, Surgical versus Nonsurgical Treatment for Lumbar Degenerative Spondylolisthesis,New England Journal of Medicine. May 2007; 356:2257-2270. (Level of evidence 2B)
41. Chang Hyun Oh et al., Slip Reduction Rate between Minimal Invasive and Conventional Unilateral Transforaminal Interbody Fusion in Patients with Low-Grade Isthmic Spondylolisthesis, Korean J Spine, 2013 (Level of evidence 2C)
42. Sairyo K., Decompression Surgery For Lumbar Spondylolysis Without Fusion: A Review Article, The Internet Journal of Spine Surgery, 2005. (Level of evidence 1A)
43. Serena S. Hu et al., Spondylolisthesis and Spondylolysis, J Bone Joint Surg Am, 2008 Mar 01;90(3):656-671 (Level of evidence 3A)
44. Tang S., Treating Traumatic Lumbosacral Spondylolisthesis Using Posterior Lumbar Interbody Fusion with three years follow up. Pakistan Journal of Medical Sciences 2014;30(5):1137-1140. (Level of evidence 3A)
45. Van Tulder M.W. et al, Conservative treatment of acute and chronic nonspecific low back pain. A systematic review of randomized controlled trials of the most common interventions, Spine, 1997; 22(18): 2128-2156 (Level of evidence 1A)
46. Overdevest G.M. et al, Design of the Verbiest trial: cost-effectiveness of surgery versus prolonged conservative treatment in patients with lumbar stenosis, BMC Musculoskeletal Disorders, 2011; 12:57 (Level of evidence 1B)
47. Sinaki M. et al. Lumbar spondylolisthesis: retrospective comparison and three year follow-up of two conservative treatment programs. Arch Phys Med Rehabil 1989 70:594-598. (level of evidence 1B)
48. Agabegi S.S. et al, Contemporary management of isthmic spondylolisthesis: pediatric and adult, The Spine Journal, 2010; 10:530-543 (Level of evidence 3A)
49. Garcia A.N. et al, Effectiveness of back school versus McKenzie exercises in patients with chronic nonspecific low back pain : a randomized controlled trial, Phys Ther, 2013; 93(6):729-47. (Level of evidence 1B)
50. Childs J.D. et al, Effects of traditional sit-up training versus core stabilization exercises on short-term musculoskeletal injuries in US Army soldiers: a cluster randomized trial, Phys Ther, 2010; 90 (10): 1404-12. (Level of evidence 1B)
51. Prateepavanich P. et al., The effectiveness of lumbosacral corset in symptomatic degenerative lumbar spinal stenosis, J Med Assoc Thai., 2001; 84(4):572-6. (Level of evidence 2B)
52. D. Winkel, orthopedische geneeskunde en manuele therapie: de wervelkolom deel 2. (Level of evidence 5)
53. Anderson T. et al, Degenerative spondylolisthesis is associated with low spinal bone density: a comparative study between spinal stenosis and degenerative spondylolisthesis, Biomed Res Int. 2013; 123847 (Level of evidence: 2A)
54. Gille O. et al, degenerative lumbar spondylolisthesis: cohort of 670 patients, and proposal of a new classification, 2014 (Level of evidence: 2A)
55. Ferrari S. et al., Clinical presentation and physiotherapy treatment of 4 patients with low back pain and isthmic spondylolisthesis, 2012 (Level of evidence: 2B)
56. Biely et al., clinical instabitlity of the lumbar spine: diagnosis and intervention., orthopedic practice vol. 18;3;06 (Level of evidence: 1B)
57. Wiltse LL. Classification, Terminology and Measurements in Spondylolisthesis. Iowa Orthop J. 1981; 1: 52–57. (Level of evidence: 2A)
58. Schneider CC. et al, Spondyloysis and spondylolisthesis; case report clarifying the etiology of spondylolysis. Radiology. 1957;69 (6): 863-6. (Level of evidence: 3B)
59. Paulo H Ferreira et al.; Specific stabilisation exercise for spinal and pelvic pain: A systematic review; Australian Journal of Physiotherapy 2006 Vol. 52 ( level of evidence 1A)
60. Matthew Garet et al.; Nonoperative Treatment in Lumbar Spondylolysis and Spondylolisthesis: A Systematic Review; SPORTS HEALTH; 2013; vol. 5 no. 3 (Level of evidence 2A
61. Farzad Omidi-Kashani et al.; Radiologic and Clinical Outcomes of Surgery in High Grade Spondylolisthesis Treated with Temporary Distraction Rod; Clin Orthop Surg. 2015 Mar; 7(1): 85–90 (level of evidence 2B)
62. Masci L. et al, Use of the one‐legged hyperextension test and magnetic resonance imaging in the diagnosis of active spondylolysis, Br J Sports Med. 2006 Nov (level of evidence 2B)
63. Monticone M. et al, Management of catastrophising and kinesiophobia improves rehabilitation after fusion for lumbar spondylolisthesis and stenosis. A randomised controlled trial , Eur Spine J. 2014 Jan (level of evidence 1B)
64. Mathias M. et al, In healthy subjects, the sitting position can be used to validate the postural effects induced by wearing a lumbar lordosis brace. , Ann Phys Rehabil Med. 2010 Oct (level of evidence 2B)
65. Roelofs PD. et al, Lumbar supports to prevent recurrent low back pain among home care workers: a randomized trial., 2007 Nov 20 (level of evidence 1B)
66. Nava-Bringas, Effects of a stabilization exercise program in functionality and pain in patients with degenerative spondylolisthesis; Journal of Back and Musculoskeletal Rehabilitation, vol. 27, no. 1, pp. 41-46, 2014 (level of evidence 2B)
67. Stephen Maya et al; Is surgery more effective than non-surgical treatment for spinal stenosis, and which non-surgical treatment is more effective? A systematic review; Physiotherapy 99 (2013) 12–20 (level of evidence 2B)
68. Antony Wicker et al; Spondylolysis and spondylolisthesis in sports; International SportMed Journal, Vol. 9 No.2, 2008 pp.74-7 (level of evidence 2B)
69. Nava-Bringasa T.I. et al; Association of strength, muscle balance, and atrophy with pain and function in patients with degenerative spondylolisthesis; Journal of Back and Musculoskeletal Rehabilitation 27 (2014) 371–376 (level of evidence 2B)
70. Kalpakcioglua B. et al; Determination of spondylolisthesis in low back pain by clinical evaluation; Journal of Back and Musculoskeletal Rehabilitation 22 (2009) 27–32 ( level of evidence 2B)
71. Kristen E. Radcliff et al.; Surgical Management of Spondylolysis and Spondylolisthesis in Athletes: Indications and Return to Play.; Curr. Sports Med. Rep., Vol. 8, No. 1, pp. 35^0, 2009 ( level of evidence 2B)
72. Margaret L. McNeely et al.; A systematic review of physiotherapy for spondylolysis and spondylolisthesis; Manual Therapy (2003) 8(2), 80–91. ( level of evidence 2B)