Espondilolistes

Prévia do material em texto

EGENERATIVE spondylolisthesis of the lumbar ver-
tebrae is frequently encountered in routine clinical
practice. Many reports are available concerning
the operative treatment of this condition.3–6,8,10 Decom-
pressive laminectomy with spinal fusion is a common
method for treating spinal instability associated with this
condition. Decompressive laminectomy without fusion is
another operative intervention for this condition. Whether
spinal fusion should be performed in patients with degen-
erative spondylolisthesis is controversial.6,7,10,11 The radio-
logical diagnosis of degenerative spondylolisthesis is not
difficult, and many clinicians believe that instability is an
important factor in the pathophysiology of this condition.
Patients with this condition often undergo surgery for low-
back pain or neurological symptoms without first being
offered conservative treatment for the aforementioned rea-
sons. Few authors have documented the clinical course 
of nonsurgically managed patients with degenerative
spondylolisthesis; the clinical course of such patients will
yield information useful for determining indications for
surgery and the choice of surgical procedures.
We previously reported on the natural course of degen-
erative spondylolisthesis;14 however, this study was not
prospective, and follow-up periods averaged only 8 years.
A longer-term prospective study was needed to determine
the final outcome of nonsurgically treated patients with
degenerative spondylolisthesis. A prospective study with
more than 10 years of follow-up data was performed in
nonsurgically managed patients to determine the progres-
sion of spondylolisthesis, changes in clinical symptoms,
and patients’ final functional abilities.
Clinical Material and Methods
Study Design
This was a prospective study with minimum 10-year fol-
low up. The study was conducted between January 1981
and October 1989; the follow-up study was continued until
October 1999. The slippage was measured by the compass
method of Morgan and King.15 Lines were drawn along ra-
J Neurosurg (Spine 2) 93:194–198, 2000
194
Nonsurgically managed patients with degenerative
spondylolisthesis: a 10- to 18-year follow-up study
SHUNJI MATSUNAGA, M.D., KOSEI IJIRI, M.D., AND KYOJI HAYASHI, M.D.
Department of Orthopaedic Surgery, Faculty of Medicine, Kagoshima University, Kagoshima, Japan
Object. Controversy exists concerning the indications for surgery and choice of surgical procedure for patients with
degenerative spondylolisthesis. The goals of this study were to determine the clinical course of nonsurgically managed
patients with degenerative spondylolisthesis as well as the indications for surgery.
Methods. A total of 145 nonsurgically managed patients with degenerative spondylolisthesis were examined annually
for a minimum of 10 years follow-up evaluation. Radiographic changes, changes in clinical symptoms, and functional
prognosis were surveyed.
Progressive spondylolisthesis was observed in 49 patients (34%). There was no correlation between changes in clinical
symptoms and progression of spondylolisthesis. The intervertebral spaces of the slipped segments were decreased signif-
icantly in size during follow-up examination in patients in whom no progression was found. Low-back pain improved fol-
lowing a decrease in the total intervertebral space size. A total of 84 (76%) of 110 patients who had no neurological deficits
at initial examination remained without neurological deficit after 10 years of follow up. Twenty-nine (83%) of the 35
patients who had neurological symptoms, such as intermittent claudication or vesicorectal disorder, at initial examination
and refused surgery experienced neurological deterioration. The final prognosis for these patients was very poor.
Conclusions. Low-back pain was improved by restabilization. Conservative treatment is useful for patients who have
low-back pain with or without pain in the lower extremities. Surgical intervention is indicated for patients with neurolog-
ical symptoms including intermittent claudication or vesicorectal disorder, provided that a good functional outcome can be
achieved. 
KEY WORDS • degenerative spondylolisthesis • spinal instability • low-back pain •
restabilization • spinal fusion
D
J. Neurosurg: Spine / Volume 93 / October, 2000
Abbreviation used in this paper: SD = standard deviation.
 
diographs of the lower and upper surface of adjacent verte-
bral bodies. The distance between the front margin of the
two adjacent vertebral bodies and the meeting point of the
two lines was measured by compass. The difference be-
tween the two distances is defined as slippage. The ratio of
displacement to the distance of the upper surface of the
lower vertebral body is defined as the percentage of slip-
page. The percentage of slippage at initial examination was
recorded as 7 to 20%, with an average of 13.6%. The site
of slippage was the L-3 vertebral body in five cases, the 
L-4 vertebral body in 125, and the L-5 vertebral body in 27.
Twelve patients had double lesions. Radiological changes,
changes in clinical symptoms, and functional prognoses
were surveyed annually by a single clinician.
Patient Population
A total of 667 patients with degenerative spondylolisthe-
sis visited our clinic from January 1981 to October 1989; at
their initial visit we recommended that 464 of these patients
undergo surgery for neurological symptoms such as senso-
ry disturbance, muscle weakness, and cauda equina symp-
toms. Four hundred twenty-four patients underwent
surgery, and the remaining 40 patients refused surgery.
Three of these 40 patients died within 10 years, and two
patients discontinued clinic visits. At initial examination
203 of the 667 patients decided in favor of conservative
treatment because they had no clearly distinguishable neu-
rological deficits except for low-back pain or pain in the
lower extremities. Conservative treatment for these patients
consisted of brace wearing, use of antiinflammatory drugs,
and/or lumbar exercises. Forty of 203 conservatively treat-
ed patients dropped out of this study during the follow-up
period, including 28 patients who died within 10 years and
12 who discontinued clinic visits. Fifty-three of the remain-
ing 163 patients underwent surgery because of the occur-
rence of neurological compromise during the follow-up
period. Development of neurological deficits was not cor-
related with progression of slippage. 
One hundred forty-five nonsurgically managed patients
(36 men and 109 women) in whom more than 10 years of
follow-up data were available were subjects of this study.
They included 110 patients who underwent conservative
treatment and 35 who refused surgery. Patient characteris-
tics are summarized in Fig. 1. Of the 145 patients, 47 were
involved in heavy labor such as farming or fishing, 41
were office workers, and 57 worked at home. Forty-six of
the 145 patients were followed until death. Their average
age at the time of initial examination was 58.6 years. The
follow-up period was 10 to 18 years and averaged 15.8
years. The age range at the end of the study period was 69
to 85 years, and the average age was 76 years.
Statistical Analysis
Nonparametric statistical analysis was performed using
the chi-square test with appropriate degrees of freedom. A
probability value of less than 0.05 was considered signi-
ficant.
Results
Radiological Changes
With the assumption that an increase in slippage rate of
5% or more constitutes progression of spondylolisthesis,
progression was found in 49 cases (34%). The final per-
centage of slippage averaged 15.6% (7–29%). A percent-
age of slippage of 25% or more was found in 10 cases.
The patients in whom a decreased intervertebral space size
was demonstrated exhibited no subsequent progression 
of slippage (Fig. 2). In contrast, 49 (96%) of 51 patientsin whom no decrease in intervertebral space size was
demonstrated exhibited progression of slippage (Fig. 3).
The degree of decrease in the size of the intervertebral
space was significantly larger in the group of 23 patients
in whom slippage did not progress as compared with the
group in whom it did (1.5 � 0.8 mm, SD). Angular dis-
placement of slipped segments was calculated based on
lateral view x-ray films with the spine in the anterior flex-
ion position. With the assumption that an angular dis-
placement of 9˚ or more constitutes instability accord-
ing to the criteria of Posner, et al.,17 this instability was de-
monstrated in 76 patients at the first visit; however, this
instability decreased over the follow-up period (Fig. 4).
Changes in Clinical Symptoms 
At initial examination 110 patients suffered from lum-
bar rheumatism, with or without pain in the lower extrem-
ities. Pain in the lower extremities was transitory, and it
was considered to be pain originating in the nerve root.
The average duration of low-back pain was 3.2 months
(1.5–6.8 months), and the frequency of episodes de-
creased with time. Eighty-five (77%) of the 110 patients
experienced improvement in their symptoms during fol-
low up. All 25 patients who experienced no change in
symptoms were heavy laborers. Finally, 84 of the 110
patients who had no neurological deficits at initial exami-
nation remained free of neurological deficits after 10 years
of follow up. The remaining 26 patients had minor neuro-
logical deficits such as numbness, but these patients did
not require surgery. Forty-eight (86%) of 56 patients who
had pain in the lower extremities experienced improve-
ment of pain with conservative treatment, but pain re-
curred in 37% of them. Twenty-nine (83%) of the 35 pa-
tients who had neurological symptoms such as those of
intermittent claudication or vesicorectal disorder due to
cauda equina syndrome at initial examination and refused
J. Neurosurg: Spine / Volume 93 / October, 2000
Nonsurgically treated degenerative spondylolisthesis
195
FIG. 1. Schematic diagram showing the disposition of 667 cases
of degenerative spondylolisthesis. Asterisk indicates the number of
patients who underwent surgery because of the occurrence of neu-
rological compromise during the follow-up period.
 
surgery experienced deterioration of these symptoms. De-
velopment of neurological deficits was not correlated with
progression of slippage. The only symptom that changed
with a decrease in intervertebral space size was low-back
pain. Eighty-five (90%) of 94 patients in whom a decrease
in intervertebral space size was demonstrated experienced
improvement of low-back pain (Fig. 5).
Final Functional Abilities in Daily Living
The 46 patients who participated in the follow-up study
for more than 10 years until the end of their lives included
31 patients who underwent conservative treatment and were
without neurological deficits at initial examination and 15
patients who refused surgery despite the presence of neu-
rological deficits. Twenty-eight of these 31 patients could
walk without assistance; however, none of the 15 patients
who refused surgery could walk without help. Eleven of
these 15 patients required a wheelchair in daily living.
Discussion
Degenerative spondylolisthesis develops as a result of a
process of degeneration of the lumbar spine.2,16 It is char-
acterized in most patients by hypertrophied arthritis of the
facet joint, resulting in segmental instability predominant-
ly in the sagittal plane.16 Disc degeneration is associated
with degenerative spondylolisthesis to a varying degree.
Decrease in intervertebral space size, the osteophytic for-
mation and ossification of spinal ligaments, and degener-
ation of the facet joint were proposed by Kirkaldy-Willis
and Farfan12 as radiographic findings of restabilization. In
our study, the patients in whom the intervertebral space
size had already decreased exhibited no subsequent pro-
S. Matsunaga, K. Ijiri, and K. Hayashi
196 J. Neurosurg: Spine / Volume 93 / October, 2000
FIG. 2. Radiographs obtained in a 61-year-old woman with progressive slippage of the L-4 vertebra. Left: Initial x-
ray film showing slippage to be 12%, with the L4–5 intervertebral space maintained. Right: Follow-up x-ray film
obtained after 7.5 years showing that the slippage has increased to 24%.
FIG. 3. Radiographs obtained in a 66-year-old woman without progressive slippage of L-3 vertebra. Left: Initial x-
ray film showing slippage to be 14%, with the L3–4 and L4–5 intervertebral spaces narrowed. Right: Follow-up x-ray
film obtained after 13.6 years showing that slippage has increased to 15%.
 
gression of slippage. This suggests that restabilization oc-
curred over the natural course of degenerative spondy-
lolisthesis. The decrease in the range of motion of the
slipped segment in our study supports the development of
restabilization.
Whether spinal fusion should be performed for the
treatment of degenerative spondylolisthesis is controver-
sial. Some authors believe that good results can be
obtained by decompression alone,6,11,19 but others have a
different opinion.3–5,10 The usefulness of fusion for treat-
ment of this condition should be evaluated based on excel-
lent results of fusion. Whether fusion is required, based on
the observations in this study of the natural course of this
condition, has not been determined. Low-back pain, the
major symptom experienced by patients with degenerative
spondylolisthesis, improved after restabilization. More-
over, spinal instability, a major pathophysiological mech-
anism associated with this condition, disappeared without
surgical fusion as a result of restabilization. Spinal fusion
procedures for instability associated with this condition
should not be performed in patients who have low-back
pain alone (except for those who engage in heavy labor).
If spinal restabilization has already occurred during the
natural course of this condition, spinal fusion procedures
are not required except when destabilization by decom-
pressive laminectomy has occurred. Fusion in patients
with spondylolisthesis is often related to the iatrogenic
destabilization, which is caused by decompressive sur-
gery. Less invasive surgery for decompression should be
attempted. If restabilization does not occur, the decision to
perform spinal fusion should be based on the patient’s age
and daily life activities. Sanderson and Wood18 recom-
mended decompressive surgery alone for elderly patients.
The mechanism of development of clinical symptoms in
degenerative spondylolisthesis is very complicated, and
intervertebral disc degeneration, facet joint degeneration,
spinal instability, compression of nerve tissues by herniat-
ed intervertebral disc, and other factors are intricately
involved.1,9,13,15 Particularly in the case of spinal instabili-
ty, no clear conclusion has been reached concerning what
extent of instability is clinically important. A better criti-
cal definition of instability is required to determine the
indication for spinal fusion.
Our clinic specializes in spine surgery, and most pa-
tients come to us to undergo surgery. It is likely that most
patients with degenerative spondylolisthesis do not pre-
sent to medical attention if they have low-back pain only
or minor symptoms. Therefore, the percentage of all
patients with this condition who undergo surgery may be
low. In the present study, many patients who had no neu-
rological deficits at initial examination remained free of
neurological deficits after 10 years follow-up study. These
findings suggest that conservative treatment is useful for
patients who have low-back pain with or without pain 
in the lower extremities. Most of patients who had neuro-
logical symptoms at the initial examination and refused
surgery suffered deterioration ofthese symptoms. The
final prognosis for these patients was very poor. Surgical
intervention is required for these patients at the onset of
symptoms or sign. 
Conclusions
This long-term prospective study on the clinical course
of nonsurgically managed patients with degenerative
spondylolisthesis provided information useful for deter-
mination of surgical indications. Conservative treatment is
useful for patients who have low-back pain or pain in the
lower extremities, given the occurrence of restabilization.
Surgical intervention to protect against the development
of severe functional disabilities is required for patients
who have neurological symptoms or signs.
References
1. Boden SD, Riew KD, Yamaguchi K, et al: Orientation of the
lumbar facet joint: association with degenerative disc disease. J
Bone Joint Surg (Am) 78:403–411, 1996
2. Bolesta MJ, Bohlman HH: Degenerative spondylolisthesis. In-
str Course Lec 38:157–165, 1986
3. Bridwell KH, Sedgewick TA, O’Brien MF, et al: The role of
fusion and instrumentation in the treatment of degenerative
spondylolisthesis with spinal stenosis. J Spinal Disord 6:
461–472, 1993
4. Caputy A, Luessenhop A: Long-term evaluation of decompres-
sive surgery for degenerative lumbar stenosis. J Neurosurg 77:
669–676, 1992
5. Cauchoix J, Benoist M, Chassaing V: Degenerative spondylo-
listhesis. Clin Orthop 115:122–129, 1976
J. Neurosurg: Spine / Volume 93 / October, 2000
Nonsurgically treated degenerative spondylolisthesis
197
FIG. 4. Graph showing the change in angular displacement of
the slipped segments in 76 patients with abnormal angular dis-
placement at presentation. Values are the means � SD.
FIG. 5. Graph showing the changes in symptoms after the onset
of decrease in intervertebral space size.
 
6. Epstein NE: Decompression in the surgical management of de-
generative spondylolisthesis: advantages of a conservative ap-
proach in 290 patients. J Spinal Disord 11:116–123, 1998
7. Feffer H, Wiesel S, Cuckler J, et al: Degenerative spondylolis-
thesis. To fuse or not to fuse. Spine 10:287–289, 1985
8. Fischgrund JS, Mackay M, Herkowitz HN, et al: 1997 Volvo
Award winner in clinical studies. Degenerative lumbar spondy-
lolisthesis with spinal stenosis: a prospective, randomized study
comparing decompressive laminectomy and arthrodesis with
and without spinal instrumentation. Spine 22:2807–2812, 1997
9. Grobler LJ, Robertson PT, Novotny JE, et al: Decompression
for degenerative spondylolisthesis and spinal stenosis at L4-5.
The effects on facet joint morphology. Spine 18:1475–1482,
1993
10. Herkowitz HN, Kurz LT: Degenerative lumbar spondylolisthe-
sis with spinal stenosis. A prospective study comparing decom-
pression with decompression and intertransverse process ar-
throdesis. J Bone Joint Surg (Am) 73:802–808, 1991
11. Herron L, Trippi A: L4-L5 degenerative spondylolisthesis: the
results of treatment by decompressive laminectomy without fu-
sion. Spine 14:534–538, 1989
12. Kirkaldy-Willis WH, Farfan HF: Instability of the lumbar spine.
Clin Orthop 165:110–123, 1982
13. Inoue S, Watanabe T, Goto S, et al: Degenerative spondylolis-
thesis. Pathophysiology and results of anterior interbody fusion.
Clin Orthop 227:90–98, 1988
14. Matsunaga S, Sakou T, Morizono Y, et al: Natural history of
degenerative spondylolisthesis. Pathogenesis and natural
course of the slippage. Spine 15:1204–1210, 1990
15. Morgan FP, King T: Primary instability of lumbar vertebrae as
a common cause of low back pain. J Bone Joint Surg (Br) 38:
6–21, 1957
16. Newman PH: Stenosis of the lumbar spine in spondylolisthesis.
Clin Orthop 115:116–121, 1976
17. Posner I, White AA III, Edwards WT, et al: A biomechanical
analysis of the clinical stability of lumbar and lumbosacral
spine. Spine 7:374–389, 1982
18. Sanderson PL, Wood PL: Surgery for lumbar spinal stenosis in
old people. J Bone Joint Surg (Br) 75:393–397, 1993
19. Silvers HR, Lewis PJ, Asch HL: Decompressive lumbar laminec-
tomy for spinal stenosis. J Neurosurg 78:695–701, 1993
Manuscript received January 17, 2000.
Accepted in final form June 26, 2000.
Address reprint requests to: Shunji Matsunaga, M.D., Depart-
ment of Orthopaedic Surgery, Faculty of Medicine, Kagoshima
University, 8-35-1, Sakuragaoka, Kagoshima 890-8520, Japan.
email: shunji@med1.kufm.kagoshima-u.ac.jp.
S. Matsunaga, K. Ijiri, and K. Hayashi
198 J. Neurosurg: Spine / Volume 93 / October, 2000