Author(s): Sharon Ong, MD, Ziva Petrin, MD
Originally published: February 12, 2014 Last updated: June 9, 2022
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Disease/ Disorder

Definition

The terms spondylolysis and spondylolisthesis are derived from the Greek roots “spondylos” meaning vertebrae, “lysis” meaning loosening, and “olisthesis” meaning slippage or dislocation.

Spondylolysis refers to a defect or fracture of the vertebral pars interarticularis. Spondylolysis may be unilateral or bilateral and occurs almost exclusively in the lumbar spine with L5 level being most often.1 Unilateral pars defects do not typically progress to spondylolisthesis.2

With spondylolysis, slippage of one vertebra on another may occur. This is known as spondylolisthesis and refers to forward translation of one vertebral segment over the one beneath it.

Spondylolisthesis of L5 over the sacrum was first described by Herbinaux in 17823, but Kilian was the first to use the term spondylolisthesis in 18544.

Meyerding described the first grading of spondylolisthesis in 1932.5 This quantifies the degree of slippage of one vertebral body on another on a standing neutral lateral radiograph of the lumbar spine. The extent of slipping is considered a major prognostic factor. Five grades are included in the Meyerding classification system:

  • Grade I: 0–25%
  • Grade II: 25- 50%
  • Grade III: 50–75%
  • Grade IV: 75–100%
  • Grade V: greater than 100% (also termed spondyloptosis)

Spondylolisthesis can occur due to a variety of etiologies. This article focuses on pediatric and adolescent spondylolysis and spondylolisthesis. Spondylolisthesis due to bilateral intervertebral pars fracture is also called isthmic spondylolisthesis or spondylolytic spondylolisthesis. In pediatric patients, dysplastic causes and isthmic defects are the predominant causes of spondylolisthesis.

Etiology

The etiology of pediatric spondylolysis is multifactorial. Genetic and congenital factors combined with biomechanical stress play major roles. Biomechanical stress through the lumbosacral spine with walking and upright posture may contribute to the development of spondylolysis because the disease has not been described in newborns or non-ambulatory children.6 Repeated mechanical stress7 on the lumbar spine is thought to cause a stress response in the pars growth plate, or once this is ossified, a fatigue fracture of the pars interarticularis. Spondylolysis typically occurs in children during periods of active growth or in adolescents with high activity, especially extension-based activities which load the pars interarticularis.8 Changes at the pars interarticularis occur on a spectrum, starting with bone stress reactions of the pars interarticularis, progressing to fracture of the pars (spondylolysis) and with bilateral defects can progress to slippage of the vertebral body (spondylolisthesis).

All three types of bony changes can be found in pediatric and adolescent patients on radiological imaging. These radiographic findings can be asymptomatic; however they are typically thought to cause low back or buttock pain worse with activity.9

The most common classification of etiological for spondylolisthesis was described by Wiltse et al in 1976. This is a descriptive classification of etiologies but does not help define severity or prognosis of the disease. Six types are described by Wiltse.10

  • Type I: congenital or dysplastic
  • Type II: isthmic
    • IIA: lytic separation of pars
    • IIB: elongated but intact pars
    • IIC: acute pars fracture
  • Type III: degenerative
  • Type IV: traumatic
  • Type V: pathologic
  • Type VI: postsurgical

In 1982 Marchetti and Bartolozzi introduced another classification system which differentiates between dysplastic causes and acquired causes. It additionally divides developmental spondylolisthesis into low-dysplastic and high-dysplastic.11,12 Children with dysplastic spondylolisthesis are more likely to have progression of spondylolisthesis (32%) than with isthmic type (4%).13

A newer classification system proposed in 2009 by the Spinal Deformity Study Group proposed six types in this classification system, which combines the severity as assessed by the Meyerding grading and combines this with an assessment of underlying radiographic spinal alignment, including global sagittal balance and sacro-pelvic alignment, which may be useful for prognostication.14

Epidemiology including risk factors and primary prevention

  • Asymptomatic spondylolysis and spondylolisthesis are estimated to occur in 5-10% of the population.15, 16
  • Prevalence varies with ethnicity: up to 54% Inuit, 6% to 11% white, and 2% African American.16-19
  • Males are affected more commonly than females, estimated 2 to 3 times more often.2,20,21
  • There is a significant association with family history. Approximately 20% of first-degree family relatives will demonstrate similar radiological changes.10,22
  • Prevalence of spondylolysis in young children increases with age. In a study of 532 children under 8 years of age found 1% in children under 3, 3.7% in children under age 6, and total prevalence of 4.7%.23
  • Spondylolysis and spondylolisthesis are more common in individuals with Down syndrome. In one study looking at prevalence in patients with Down syndrome, spondylolysis was described in 18.7% of and spondylolisthesis in 32.7% of patients.24
  • Spondylolysis is a common cause of low back pain in adolescent athletes. Prevalence in 136 children under the age of 19 with back pain found a spondylolysis prevalence of 39.7%. All of these patients had a history of athletic activity.25
  • In a case series of 1025 adolescent athletes with low back pain (age 15 +/- 1.8 years) 30% were diagnosed with spondylolysis.26 In this study, male athletes with spondylolysis were most likely to participate in baseball (54%), soccer (48%) and hockey (44%), and female athletes most likely to participate in gymnastics (34%), marching band (31%) and softball (30%)
  • Also commonly identified in gymnastics, weightlifting, football, and diving athletes.19
  • There is an increased risk with spina bifida occulta.27,28
  • There is a contributive role for vitamin-D deficiency.29,30

Prospective study examining the natural history of spondylolysis and spondylolisthesis of 500 individuals over 45 years of follow up revealed the following:

  • At initial recruitment period at age 6, 4.4% of the 6-year-old subjects had pars interarticularis defects (16 bilateral defects, 6 unilateral defects).
  • Subjects with unilateral defect never experienced slippage.
  • 62.5% of subjects with bilateral pars defects also had spondylolisthesis at the time of diagnosis.
  • At final follow-up 81.8% of subjects with bilateral spondylolysis also had spondylolisthesis.
  • There was a marked slowing of progression of spondylolisthesis with each decade.2

Patho-anatomy/physiology

The most common types of spondylolisthesis in the pediatric population are dysplastic (type I) and isthmic (type II).10 These two types of spondylolisthesis have significantly different natural histories.

Developmental or dysplastic spondylolisthesis are more likely to progress. This is due to underlying anatomy, including the spinopelvic parameters and specific morphology such as growth deficiencies of the anterosuperior sacrum.11 Dysplastic spondylolisthesis may also be related to conditions such as hypoplastic vertebral bodies31, spina bifida at L5 or S1, and other various spine morphology abnormalities.14,16,27,32

Isthmic spondylolisthesis occurs typically as a result of spondylolysis or pars defect. Lumbar extension causes the inferior articular process of the cephalad vertebra to abut the pars interarticularis of the caudal vertebra.7 Repeated lumbar hyperextension and rotation required in certain sports impart repetitive stress to the incompletely ossified pars interarticularis or vertebral growth plate and apophyseal bony ring. This may eventually lead to a stress reaction, followed by linear fracture or spondylolysis. A higher rate of isthmic spondylolysis in athletes may be attributed to repetitive lumbar hyperextension, with isthmic spondylolytic defects overwhelmingly occurring at the L5 vertebral level, and more common on the non-dominant side (site of maximum compression due to extension and rotation contralateral to the dominant limb such as occurs when kicking or throwing a ball).19

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

Beutler et al studied the natural history of spondylolysis and spondylolisthesis in subjects over a 45-year period. The average slip progression was 7% in the first decade, 4% in the second and third decades, and 2% in the fourth decade of follow-up evaluation. No increased rates of low back pain or disability as measured by the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) were identified compared with the general population. Even with bilateral pars defects, most pediatric patients will remain asymptomatic through adulthood. In fact, of the 30 original study subjects, only 1 episode of pain was noted.2

In summary, the development of spondylolisthesis and its progression appear to be most prominent during growth spurts, with minimal progression occurring after skeletal maturity.20

Spondylolysis with grade I spondylolisthesis: clinical follow-up
In a 2009 meta-analysis of nonoperatively managed patients, 83.9% of 665 patients had a satisfactory outcome after 1 year.33

Spondylolysis with grade I spondylolisthesis: radiographic follow-up
In the same meta-analysis, unilateral pars defects healed at a rate of 71.1% compared with bilateral defects at 18.1% after 1 year.33

Bilateral spondylolysis: incidence of spondylolisthesis and slip progression
In a study of 255 patients (in contrast with asymptomatic subjects in the observational study previously mentioned) between the ages of 9 and 40 years diagnosed with bilateral L5 spondylolysis with or without spondylolisthesis, results on initial evaluation were as follows:

  • 19% had spondylolysis without spondylolisthesis
  • 54% had grade I spondylolisthesis
  • 27% had grade II spondylolisthesis or higher

After a minimum of 20-year follow-up, 91% of these patients had experienced low back pain at some point. Mean progression of vertebral slippage in adolescents (< 18 years) was 2.5 mm. In 11% of this adolescent population, progression was greater than 10 mm.34

Specific secondary or associated conditions and complications

High-grade spondylolisthesis (>50% slip on the Meyerding scale) can be associated with chronic back pain, radicular symptoms, neurogenic claudication, and disk degeneration.

Essentials of Assessment

History

Important aspects to include in the history are as follows:

  • Back pain onset, quality, severity, location, and radiation, and associated symptoms
  • Neurologic involvement (including sensation changes, muscle weakness, bladder or bowel incontinence)
  • Exacerbating and remitting positions and activities
  • Participation in sports, specifically type of sport, chronic training load and any acute changes in training load
  • Previous diagnostic work-up, treatments, and response
  • Family history of spina bifida or spondylolysis or spondylolisthesis.
  • Review of systems

Physical examination

Many patients with spondylolysis and low-grade spondylolisthesis have unremarkable physical examinations.

Gait changes have been described in high-grade spondylolisthesis. These include increased posterior pelvic tilt, reduced hip and knee extension due to hamstring tightness.35

Inspection

  • Generally normal

Palpation

  • Palpation is typically negative or may be positive over the spinous process or lateral to spinous process over pars in spondylolysis
  • High specificity (87%-100%) and moderate to high sensitivity (60-88%) have been described for lumbar spinous process palpation for lumbar spondylolisthesis36
  • There may be a palpable step-off at a level of high-grade spondylolisthesis.  Step-deformity palpation demonstrated 60-88% sensitivity and 87-100% specificity for spondylolisthesis in systematic review.37

Range of motion

  • Limited range of motion in all planes in acutely symptomatic patients.
  • Pain and range of motion limitations usually worsened with spine extension
  • Hamstring tightness in symptomatic patients.

Neurologic

  • Normal neurologic exam is expected with spondylolysis and low-grade spondylolisthesis.
  • Radicular symptoms and bladder or bowel dysfunction may be present with high-grade spondylolisthesis.

Special tests

  • The one-legged back hyperextension test (Stork test) is the most commonly used physical examination test for spondylolysis assessment however has low to moderate sensitivity (50%-73%) and low specificity (17%-32%) to diagnose lumbar spondylolysis. As such, the clinical utility of this test is low.
  • Straight-leg raise test may reveal nerve root irritation in high-grade spondylolisthesis.

Functional assessment

In patients with isthmic spondylolysis, causative sporting movements should be observed to evaluate for any biomechanical deficiencies that may be loading the pars.

Imaging

There is controversy regarding best imaging modalities to diagnose spondylolysis.

Pain stemming from the pars intervertebralis can be due to bone stress reaction without presence of new linear fracture, and bone stress reactions are not visible with plain radiograph or CT imaging. Additionally, as prevalence of asymptomatic spondylolysis is high, many patients present with pain due to new irritation of a previously present but asymptomatic pars defect, or may present with new irritation of a previous fibrous union of a pars defect. As such, appropriate imaging modalities need to be used based on the history, chronicity of the complaint, age, sex and examination of the child.

Use of oblique radiographs is controversial, and these should not be used as a screening test for low back pain in pediatric patients. Oblique views have been shown not to improve the sensitivity and specificity of radiographic assessment as compared to use of 2-view (anteroposterior and lateral) radiographs, and there is no diagnostic benefit that outweighs the cost and radiation exposure.38,39

Likewise, CT scan is not an imaging of choice in children as it not able to define bone stress reaction. A study looking at imaging modalities in pediatric patients with new-onset low back pain found that 19.6% of the pars intervertebralis stress injuries will be CT-negative.40

MRI is radiation-free, and an imaging of choice in pediatric patients to assess bone stress reaction and neurological symptoms. It can also identify other causes of low back pain other than spondylolysis.

Single-photon emission computed tomography (SPECT) is superior to plain radiographs but is limited by high false positive and false negative results and radiation exposure.41

Bone scintigraphy can differentiate acute spondylolysis from old chronic nonunion fracture, and there is good correlation between a positive bone scan and painful pars lesion, however findings are otherwise nonspecific. Bone scan with SPECT may be superior to either MRI and CT in the detection of spondylolysis.42

Dysplastic spinopelvic anatomy and spondylolisthesis can be seen on plain radiographs. Lateral views allow for quantification of vertebral displacement according to Meyerding grading system as well as to assess for slip angle, pelvic incidence and sacral inclination angles in dysplastic spondylolisthesis. Standing flexion and extension views are used to evaluate for dynamic instability of the spondylolisthesis. Dynamic instability means there is anterior or posterior movement of the vertebral bodies relative to each other during flexion or extension.

RadiographInterpretation
Anterior-posteriorStanding flexion/extension films assess alignment and dynamic anterior-posterior instability.
LateralDegree of vertebral displacement can be quantified using the Meyerding grading system. Dysplastic spinopelvic anatomy, slip angle, pelvic incidence, and sacral inclination can be assessed in the lateral view.
ObliqueSensitivity and specificity are equal to 2-view radiographs, but radiation dose is approximately double.43 A pars fracture appears as a collar on the Scotty dog.
Imaging modalitiesIndications/special aspects
Computed tomographyCompared with a plain radiograph, a computed tomography scan is more sensitive in visualizing pars interarticularis lesions.39 Effective radiation dose is greater than double as compared to 2-view radiographs.  
Bone scanMetabolically active bony lesions can be visualized with a bone scan. As compared to 2-view radiography, bone scans have a seven to nine time the effective radiation dose.43 Bone scan findings are nonspecific.
SPECTCompared with single-photon emission CT (SPECT), the average sensitivity of CT is 85% and the sensitivity of MRI is 80%.43  
Magnetic resonance imaging (MRI)Imaging of choice in children due to lack of radiation and ability to assess other structures. Indicated if neurologic signs/symptoms are present. MRI can be useful to assess disease chronicity; hyperintensity of the pars interarticularis on T2-weighted or short TI inversion-recovery sequences suggests an acute process.44

At present, there are no established guidelines for advanced imaging modalities in patients with spondylolysis.

Mechanical low back pain is common in children and adolescents, and treatment (activity modification, physical therapy) can be instituted without the need for imaging in the majority of cases. In children who fail to improve with this initial approach, 2-view imaging of the lumbar spine can be obtained with clinical suspicion of spondylolysis or spondylolisthesis. Plain radiography is sufficient to assess for dysplastic changes and may reveal a spondylolysis. When bone stress reaction is suspected initial advanced imaging of choice is MRI. SPECT or bone scan can be used for persistent or refractory cases.39,45

Early predictions of outcomes

Results of a retrospective study on the natural history of spondylolysis and spondylolisthesis indicated that pediatric subjects with spondylolysis do not appear to have an increased likelihood of disability or chronic pain in adulthood as assessed by a back pain questionnaire at the 25 year follow-up and the SF-36 at the 45 year follow-up.2

In fact, some controversy exists whether spondylolysis and spondylolisthesis are necessarily the cause of low back pain, or represent an incidental radiological finding in some cases.8

Social role and social support system

Spondylolysis typically begins in adolescence; therefore, parental education is important to ensure proper follow-up with health care providers. Athletes participating in certain sports such as gymnastics, weightlifting, soccer, and football are at a higher risk given repetitive flexion/extension movements of the spine. A goal of early treatment is to prevent progression and to limit prolonged absence from sport.

Rehabilitation Management and Treatments

Available or current treatment guidelines

At present, there are no consensus guidelines for symptomatic spondylolysis treatment.

Clinical recommendations are mostly based on expert opinion. Current practice commonly entails a trial of conservative management, including relative rest, sports activity modification, physical therapy and graduated return to sports.

The use of bracing is controversial. A number of studies have shown equivalence of conservative management outcomes with and without bracing. Review of fifteen observational studies measuring the clinical outcome with conservative treatment shows weighted and pooled success rate of 83.9% in 665 patients with no significant difference in clinical outcome of patients treated with a brace to patients treated without a brace.33 Additionally, discomfort and poor compliance with bracing is a main limiter for many patients and use of bracing should be determined on a case-by-case basis.

At different disease stages

Spondylolysis and Low-Grade Spondylolisthesis (<50%)

Acute management

  • Modification or cessation of sporting activity

Rehabilitation

  • Initiate physical therapy focused on optimizing spino-pelvic biomechanics
  • Physical therapy includes core and pelvic stabilization and strengthening exercises, hamstring range of motion exercises.46,47
  • Transition from outpatient physical therapy to home exercise program

Monitoring

  • Asymptomatic spondylolysis and/or low-grade isthmic spondylolisthesis do not require routine follow-up or imaging
  • Symptomatic (pain, deformity, or hamstring muscle tightness) spondylolysis and/or low-grade isthmic spondylolisthesis should be followed clinically for resolution of symptoms
  • Low-grade dysplastic spondylolisthesis should be followed serially with routine examination and imaging to ensure stability, especially during periods of peak growth when progression is most likely to occur.

Surgical management

  • Surgical management is reserved for refractory cases, in persistently symptomatic but stable spondylolysis and/or low-grade spondylolisthesis
  • Surgical management is indicated for refractory pain despite conservative management for a minimum of 6 months, new or progressive neurologic deficits, instability as conferred by multilevel pars defects

High-Grade Spondylolisthesis (>50%)

  • Risk of slip progression is a concern in the “high grade” or dysplastic type. Surgical treatment is commonly recommended to prevent progression. Conservative treatment with serial monitoring for symptoms can be trialed initially depending on morphology.
  • There is Level III evidence that patients with a higher slip angle are more likely to fail medical/interventional treatment of high-grade spondylolisthesis.
  • Surgical instrumentation and reduction lower the risk of nonunion. There is Level III evidence that circumferential fusion is superior to posterior-only or anterior-only fusion.48

Coordination of care

The physiatrist plays an important role in maintaining open communication within the treatment team, which also consists of a primary care physician, physical therapists, and in some cases, surgeons. The outlined treatment plan must be transparent; therefore, the family members, coaches, and athletic trainers are well informed.

Patient & family education

Generally, pediatric patients with asymptomatic spondylolysis or low-grade spondylolisthesis may participate in sporting activities without restrictions.

In symptomatic pediatric patients, appropriate treatment of unilateral, incomplete, and early spondylolysis lesions can result in bony union. With or without bony union or spondylolisthesis, most patients have resolution of symptoms in the short-term.

Most patients will have similar lumbar symptoms as compared with the general population after treatment and patients may anticipate a benign course into the later decades of life with only a small group likely to develop symptoms secondary to slip progression. There is currently insufficient evidence to predict which patients will develop significant symptoms as adults and will undergo surgical treatment.48

Emerging/unique interventions

N/A

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

  • Mechanical low back pain in pediatric patients is generally benign, and treatment consisting of activity modification and addressing underlying biomechanical deficits is an appropriate first step
  • Use of oblique views is not supported by evidence for diagnosis of spondylolysis.
  • 2-view radiographs of the lumbar spine are an initial imaging of choice to assess for dysplastic morphology and presence and grading of spondylolisthesis. In pediatric patients, MRI is an excellent choice for advanced imaging as it is radiation-free, and also helps identify other causes of low back pain. Other imaging including SPECT should be used for refractory cases or with specific indications.
  • Conservative management with activity modification and physical therapy is effective for symptoms reduction and there is a high return to sports outcome for spondylolysis.
  • There is insufficient evidence to support use of bracing for treatment of spondylolysis.
  • Dysplastic morphology and high-grade spondylolisthesis should be monitored closely, especially during periods of peak growth, as are at higher risk of progression of slippage.
  • Surgery may be indicated in patients with progressive slippage, neurologic deficits, or intractable pain after 6 months of conservative management.

Cutting Edge/ Emerging and Unique Concepts and Practice

N/A

Gaps in the Evidence-Based Knowledge

Consensus management guidelines for various stages of spondylolysis and spondylolisthesis are currently not available.

Data assessing efficacy of various braces, casting, and surgical procedures are limited.

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Original Version of the Topic

David S. Cheng, MD, Craig Best, DO, Kashif Saeed, MD. Pediatric Spondylolysis and Spondylolisthesis. 2/12/2014

Previous Revision(s) of the Topic

Caroline A. Schepker, MD, Katherine Yao, MD, Yodit Tefera, MD. Pediatric Spondylolysis and Spondylolisthesis. 5/29/2018

Author Disclosure

Sharon Ong, MD
Nothing to Disclose

Ziva Petrin, MD
Nothing to Disclose