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TYPE
Original Research
PAGE NO.
80-89
10.37547/tajmspr/Volume07Issue03-11
OPEN ACCESS
SUBMITED
12 January 2025
ACCEPTED
21 February 2025
PUBLISHED
20 March 2025
VOLUME
Vol.07 Issue03 2025
CITATION
Bianca Gabriella de Oliveira, Rodrigo Moreira Garcia, Jorge da Silva
Castro, Filipe Alves Chagas, Igor Campos Roubert, & Marcella Rodrigues
Costa Simões. (2025). Surgical versus non-surgical treatment for the
staging of spondylolisthesis: systematic review and meta-analysis. The
American Journal of Medical Sciences and Pharmaceutical Research,
80
–
89. https://doi.org/10.37547/tajmspr/Volume07Issue03-11
COPYRIGHT
© 2025 Original content from this work may be used under the terms
of the creative commons attributes 4.0 License.
Surgical versus non-
surgical treatment for the
staging of
spondylolisthesis:
systematic review and
meta-analysis
Bianca Gabriella de Oliveira
Acadêmico de Medicina pela Universidade Salvador-UNIFACS,
Salvador, BA, Brasil
Rodrigo Moreira Garcia
Médico residente de Ortopedia e Traumatologia pelo Hospital Estadual
de Traumatologia e Ortopedia Dona Lindu, Rio de Janeiro, RJ.
Jorge da Silva Castro
Médico residente de Ortopedia e Traumatologia pelo Hospital Estadual
de Traumatologia e Ortopedia Dona Lindu, Rio de Janeiro, RJ.
Filipe Alves Chagas
Médico residente de Ortopedia e Traumatologia pelo Hospital Estadual
de Traumatologia e Ortopedia Dona Lindu, Rio de Janeiro, RJ.
Igor Campos Roubert
Médico residente de Ortopedia e Traumatologia pelo Hospital Estadual
de Traumatologia e Ortopedia Dona Lindu, Rio de Janeiro, RJ.
Marcella Rodrigues Costa Simões
Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil.
Corresponding author:
Bianca Gabriella de Oliveira.
Rua Araçari, number 18, bairro Muchila 2 (dois), Feira
de Santana - Bahia, CEP 44005756.
E-mail: bianca.oliveira43@gmail.com.
Conflict of interest
Not applicable
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The American Journal of Medical Sciences and Pharmaceutical Research
Funding
This study did not receive any financial support from
public, commercial or non-profit sources.
Abstract:
Objective:
To evaluate the limits of conservative
treatment compared to surgical treatment.
Methodology:
Information was searched using the
Pubmed
database
using
the
keywords:
"developmental", "spondylolisthesis", "classification",
"surgical", "treatment", "graft", "fusion", "Gaines". The
search was restricted to articles in English, French and
Portuguese. After selection, 05 articles were consulted
for analysis and construction of the study.
Results:
Surgical treatment proved to be more effective
in assessing pain in studies in which the patients were
children and adolescents. Conservative treatment, in
the majority of studies, was not effective in terms of
improving mental health and consequently improving
the quality of life experienced by the patient.
Conclusion:
Conservative treatment is indicated as the
first choice in most cases, leaving the invasive option
for residual symptoms or advanced degrees of
anatomical involvement, and it is worth noting that the
surgical procedure is shown in the evaluation of pain,
mental health and quality of life in the studies in which
the patients were children and adolescents.
Keywords:
spondylolisthesis;
developmental;
treatment; classification; review; reduction; fusion.
INTRODUCTION:
It was first described in 1782 as an anterior prominence
of the sacrum that causes narrowing of the birth canal,
supposedly caused by a subluxation in the 5th lumbar
vertebra over the 1st vertebral column of the sacral
spine. It evolved 12 years later to the term
spondylolisthesis of Greek origin, which corresponds to
“slippage,” which affects the anatomical region of the
spine and has an etiology that is not well established
with a multifactorial origin, namely mechanical,
hormonal and hereditary factors. Spondylolisthesis is
the anterior or posterior slippage or displacement of
one vertebra over another and may be a unilateral or
bilateral lesion of the isthmus without slippage of the
vertebra, and is called spondylolysis. ¹
The clinical presentation is variable and extensive in
view of the possibility of anatomical involvement: 1.
minimal vertebral slippage with exuberant symptoms
and 2. exuberant vertebral slippage with minimal or no
symptoms. The presence of low back pain and/or
lumbosciatica
of
radicular
origin,
due
to
compression/stretching of the roots, are the most
common symptoms. Therefore, the diagnosis changes
according to the manifestation, from the accidental
discovery through imaging tests performed for other
pathological causes. It affects the general population
with an incidence of 4-8% and twice as high as that of
men, relatively common in the pediatric population.
1,2,3
Anatomically, the spine plays an important role in the
stability and general balance in the coronal and sagittal
planes of the spine, given by the integrity of the osteo
discoligamentous complex. Thus, the lumbosacral level
of stability depends on the spatial orientation of the 5th
lumbar vertebra in relation to the sacrum, lumbosacral
angle, sacral slope and pelvic incidence, and an intact
osteo discoligamentous complex. Therefore, the
involvement of the pathology causes deformation of
the sacral in growing children, which can have an
impact on the development of the locomotor
system.,2,3
As for complementary exams, simple radiographs in the
orthostatic position are sufficient and well indicated to
diagnose the disease in cases with a lower degree of
slippage. Bone scintigraphy is useful in identifying acute
fractures and pseudarthrosis in old fusion areas, aiding
in the prognosis. 3D computed tomography allows the
identification of compression of nerve roots by soft
tissues and the identification of bone inside and outside
the spinal canal. And magnetic resonance imaging
allows the assessment of disc degeneration, which may
be useful for determining the extreme upper limits of
fusion and assisting in the therapeutic procedure.2,3,4
There
are
many
therapeutic
options
for
spondylolisthesis: limitation of activities, exercises,
especially hip flexion, immobilization, repair of the
isthmic defect, fusion, decompression with/without
fusion, and finally, partial/total reduction and fusion.
This leads to the classic orthopedic dilemma: surgical or
conservative treatment? Thus, the general criteria for
indication for surgical treatment include persistent pain
or neurological symptoms in the face of good
conservative application, progression of the slippage
greater than 30%, a degree of slippage at presentation
equal to or greater than Meyerding grade 3, and the
existence of a cosmetic deformity associated with
postural and gait difficulties. Overall, only 20% of
patients with symptomatic spondylolisthesis require
surgical treatment.3,4,5,6
Although conservative approaches are successful in
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children and adolescents, during development there
are more presentations of spondylolisthesis with a high
degree of slippage or with progression of the lesion,
therefore requiring surgical intervention. It is suggested
that risk factors associated with progression in the
younger population are age under 15 years, presence
of slippage greater than 30%, ligamentous laxity,
female gender and lumbosacral hypermobility
(presence of rounding of the upper platform of S1 and
concavity of the lower surface of L5). 3,4,5,6
Thus, this proposed article aims to evaluate the limits
of conservative treatment compared to surgical
treatment, through a systematic review with meta-
analysis, assisting in the therapeutic management of
patients and in the prognosis of the pathology.
METHODOLOGY
A systematic literature search on the prevalence of
spondylolisthesis in children was carried out. General
information on the study patient characteristics and the
prevalence of spinal abnormalities was extracted from
the studies. Prevalence data for the most commonly
reported abnormalities were pooled using random
effects proportion meta-analysis. The study protocol
was prospectively registered in PROSPERO under ID
CRD42024519351.
Data sources
The information was searched using the Pubmed
database using the keywords: “developmental”,
“spondylolisthesis”,
“classification”,
“surgical”,
“treatment”, “graft”, “fusion”, “Gaines”. The search
was restricted to articles in English, French and
Portuguese. After selection, 05 articles were consulted
for analysis and construction of the study.
Data synthesis:
There are currently two classification systems with
wide global acceptance, the Wiltse, Newman and
MacNab classification system and the Marchetti and
Bartolozzi classification system. The latter proposes a
new
subtype
of
spondylolisthesis,
which
is
developmental spondylolisthesis. However, this
classification system was not established as a guide for
surgical treatment and was not based on the sagittal
spinopelvic balance, which is considered by several
authors as an important parameter in the pathogenesis
and treatment of developmental spondylolisthesis.
Therefore, Jean-Marc Mac-Thiong and Hubert Labelle
proposed a new classification of lumbosacral
developmental spondylolisthesis in children and
adolescents with the aim of serving as a basis for the
creation of a surgical treatment algorithm for which
there are several options.
RESULTS
Initially, 156 articles were selected, 104 were excluded
because they had been published more than 20 years
ago, leaving 52. Thirteen studies were eliminated based
on their titles and 18 were eliminated based on their
abstracts, as they did not evaluate the therapeutic
efficacy of clinical and surgical treatments. Finally, 5
articles were selected for analysis and as the basis for
the study (Figure 1).
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FIGURES
Figure 1 - Flowchart of the studies evaluated according to the PRISMA parameters.
The 5 selected articles correspond to patients
diagnosed with spondylolisthesis who underwent
surgical or conservative treatment. The population of 2
studies was children and adolescents, while the other 2
studies corresponded to elderly patients. In total, 820
patients were included. The surgical techniques used
varied, such as in situ bone fusion with posterior graft,
in situ instrumented fusion, anterior interdiv fusion,
instrumented fusion, L5 corpectomy with L4 to S1
fusion.
Table 1 presents the selected studies and their results.
8,9,10,11
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Table 1. Results obtained from the selected studies.
Table 2 contains the Visual Analogue Scale (VAS) of
patients who underwent surgical or conservative
treatment for spondylolisthesis. 8,9,10,11
Table 2- Visual Analogue Scale (VAS) of patients undergoing surgical or conservative treatment for
spondylolisthesis.
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Figure 2 presents the forest plot with the analysis of the
Visual Analogue Scale (VAS) of patients who underwent
surgical
or
conservative
treatment
for
spondylolisthesis. 8,9,10,11
Figure 2 - The forest graph with the analysis of the Visual Analogue Scale (VAS) of patients undergoing surgical
or conservative treatment for spondylolisthesis.
In the study by Lundine et al8, 24 patients were
selected for the surgical treatment group and 25 for the
conservative treatment group, of which 10 patients
subsequently required surgical intervention. The
surgical techniques used were in situ bone fusion with
posterior graft only, anterior interdiv fusion, in situ
instrumented fusion, L4-S1 instrumented fusion with
reduction, L4 pelvic instrumented fusion with reduction
and posterior interdiv graft, L5 corpectomy with L4 to
S1 fusion. The SRS-30 questionnaire (Scoliosis Research
Society) demonstrated preoperative pain values of
patients who would undergo the surgical procedure of
4.3 ± 1.1 versus 4.2 ± 1.1 postoperatively, while patients
undergoing conservative treatment reported a VAS
(Visual Analogue Scale) score of 4.2 ± 0.7 before
treatment and 4.2 ± 0.5 after it. Regarding mental
health, the surgical group reported an improvement
from 4.1±0.8 to 4.3±0.5, while the non-operative group
initially reported a score of 4.1±0.7 and after treatment
of 3.8±0.8. The total SRS-30 score of the operated
patients was 80.4±14.0 versus 79.5±11.0 non-operated.
Bourassa-Moreau et al9 included 05 patients in
conservative treatment and 28 in surgical treatment.
The technique used was primary fusion. The VAS index
ranged from 4.17±0.78 to 1.19±1.13 in patients
undergoing surgical treatment and from 4.12±0.64 to
4.00±0.62 in conservative treatment. The mental
health of patients improved both in the surgical group
(4.15±0.57 to 4.65±0.95) and in the conservative group
(4.32±0.44 to 4.44±0.33). No complications were
reported.
In the study by Weinstein et al10, 332 patients initially
underwent the surgical procedure, while non-surgical
treatment was chosen for 275 patients. During the
study, 40 patients in the non-surgical group needed to
undergo the procedure. The SPORT (Spine Patient
Outcomes Research Trial) questionnaire was applied.
The pain reported by surgical patients after the
procedure was 29.2±16.8 and non-surgical patients
34.4±16.7. The mental health reported by surgical
patients was 49.5±11.6 versus 51.3±11.3 non-surgical
patients. The Oswestry disability index for surgical
patients was 45.0±16.6 and for non-surgical patients
36.2±18.5.
Passias et al11 initially selected 145 patients to receive
non-operative treatment, however, after the beginning
of the study, 80 required the surgical procedure. The
SF-36 questionnaire was administered, and the
preoperative pain reported was 32.2±18.7 to 31.2±18
after the procedure, for non-surgical patients this
variation was 35.5±18.4 to 15.1±1.8. The surgical
Oswestry disability index was 22.6±1.4 and the non-
operative one was 29±1.4.
DISCUSSION
Surgical treatment has been shown to be more
effective in assessing pain in studies in which the
patients were children and adolescents. Regarding the
assessment of disability, the studies did not
demonstrate significant variations between the groups.
Conservative treatment, in most studies, was not
effective in improving mental health and consequently
improving the quality of life experienced by the patient.
Conservative treatment in low-grade spondylolisthesis
is the indication, due to the good results and
prognosis¹². However, there is no agreement and it is
still controversial as to what is the best treatment for
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high-grade spondylolisthesis in pediatric patients¹³.
Some researchers advocate surgical therapy in these
patients, despite the clinical presentation, with the
argument of preventing slippage and progression of
symptoms¹⁴. Others suggest that conservative therapy
may be indicated in less symptomatic or asymptomatic
high-
grade spondylolisthesis¹⁵
﹐
¹
⁶.
The role of conservative treatment in small patients
with high-grade slippage¹² is not yet well understood.
However, it is known to include non-steroidal anti-
inflammatory medication, physiotherapy, activity
modification and immobilization with a brace¹⁷. The
focus of physiotherapy is on relieving tension in the
extension of the lumbosacral junction, stretching the
hip flexors and hamstrings, working the deep
abdominal muscles and strengthening the lumbar
mul
tifidus¹⁷
﹐
¹
⁸
﹐
¹
⁹. There have been reports of good
results with the use of these therapies²⁰. However,
these studies are usually retrospective and with
different patient populations, thus limiting the validity
of their effects¹³.
Surgical treatment is usually indicated for patients who
have undergone conservative treatment without
improvement, who continue to have symptoms and
neurological deficits²¹
﹐
²². In particular, growing
children with high-grade spondylolisthesis usually
require surgical intervention due to the high risk of
compression. An absolute indication is cauda equina
syndrome, but motor weakness, low back pain and
radicular pain in the lower limbs are also strong
indications. In adolescents, the progression of slippage
is a relative indication²³.
Although there are numerous surgical options, and it is
not yet known which is the best²⁴, the primary aim of
surgery is to achieve a solid fusion to correct the
deformity in order to achieve vertebral balance and
perform neurological decompression²³
﹐
²
⁵. Some of
the operative techniques used are in situ bone fusion
with posterior graft only, anterior interdiv fusion,
instrumented in situ fusion, instrumented L4-S1 fusion
with reduction, instrumented L4 pelvic fusion with
reduction and posterior interdiv graft, L5 corpectomy
with L4 to S1 fusion. 8,9,10,11,12
One of the last preoperative decisions to be made
involves which levels will be fused, whether it
incorporates the pelvis and whether it needs to provide
support for the anterior column²³. Many surgeons have
used
monosegmental
fusion
for
high-grade
spondylolisthesis²⁶. However, even when associated
with anterior column support, posterior fusion of L5/S1
alone was related to a nonunion rate of 17% in a study
of 34 patients²⁶ and a structural compl
ication rate of
11% in another study of adolescents²⁷. Both authors
therefore recommended fusion of L4 to S1²⁶
﹐
²
⁷.
Although proximal fixation usually ends at L3 or L4,
distal fixation can end at S1²⁸ or incorporate the
ileum²⁹. In children and adolescents,
distal fixation at S1
or S2 works well, but older patients with high-grade
slippage, an open S1/S2 disc space, poor sacral bone
quality or connective tissue disease may benefit from
an increased iliac screw²³.
For low-grade spondylolisthesis, a well-known
technique and many surgeons report good clinical
results is posterolateral fusion in situ³⁰. However, in
high-grade spondylolisthesis, the procedure is
favorable to a significant rate of non-union or
subsequent progression of delamination³¹.
Furthermore, circumferential fusion facilitates sagittal
balance and local kyphosis³². Two recent meta-analysis
studies observed that this technique takes longer than
instrumented posterolateral fusion, but achieves a
better fusion rate, restoration of alignment and clinical
satisfaction³³.
There is much debate about whether or not to reduce
high-grade spondylolisthesis, due to the difficulty of the
procedure, questions about the benefit and associated
complications, especially neurological²⁴
﹐
³
⁴
﹐
³
⁵
﹐
³
⁶.
Some authors report good results with in situ fusion,
especially in patients with preserved pelvic balance²⁴
﹐
³
⁷. Others consider in situ fusion to be better than
gradual reduction, distraction and milled fusion³⁸.
Most of the apprehension is because of the risk of
neurological injury and, although the reason for
reduction is multifactorial, there is evidence that it is
safe and biomechanically preferable²³.Even though
there have been reports of nerve root injury following
this maneuver³⁴
﹐
³
⁵. Some recent and larger studies
show a prevalence of neurological deficit in the order
of 5% to 10%³⁴
﹐
³
⁵
﹐
³
⁹. A recent search of the Scoliosis
Research Society Morbidity and Mortality database
showed a neurological deficit in nine out of eighty-eight
pediatric patients³⁵.
The ability to achieve direct neural decompression can
avoid the risk of acute cauda equina syndrome in the
post-
operative period⁴⁰. It also makes it possible to
correct the local anatomy, since the surgeon can
directly influence the sliding angle and sliding
percentage
⁴¹, thus improving the overall sagittal
alignment²³. This is one of the main reasons for its use⁴²
﹐
⁴³.
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A retrospective study by Martiniani et al.³⁴ showed that
patients with unbalanced deformities who underwent
reduction and fusion recovered with improvements in
sacral and pelvic inclination. Supporting the idea that
patients with unbalanced high-grade spondylolisthesis
benefit more from reduction than those with balanced
high-
grade spondylolisthesis⁴²
﹐
⁴³.
Due to the change in local forces, this reduces the risk
of pseudoarthrosis²³. Numerous studies have revealed
an increase in this risk in patients who have not had the
reduction³⁴.This is most likely due to the continued
presence of shear forces through the lumbosacral disc
space, which puts excessive stress on the implants,
leading to non-
consolidation, loosening and failure⁴¹.
Post-operative patients are warned and advised to
avoid knee extension with hip extension, so that the
lumbar plexus is not stretched. In the first 48 hours,
neurological tests assess the motor strength of the
tibialis anterior, extensor hallucis longus and
quadriceps. Narcotics are offered as drug therapy for
pain relief, and diazepam is used to relieve spasms. In
some cases, gabapentin is useful to control temporary
radiculitis. Most patients are discharged from hospital
on the third or fourth day²³.
CONCLUSION
Spondylolysis and spondylolisthesis are known to be
common etiologies of low back pain in the pediatric and
adolescent population. This leads to functional
limitations
in
sports
that
require
repetitive
hyperextension of the lumbar spine, although the
asymptomatic form is common.
The clinical presentations in the mild forms include low
back pain, radiculopathy, postural alterations and,
rarely, neurological deficits. Therefore, the need for a
thorough physical examination associated with imaging
tests has an important diagnostic and prognostic
outcome. Added to this is the potential risk of
pathological progression.
Conservative treatment is indicated as the first choice
in the majority of cases, leaving the invasive option for
residual symptoms or advanced degrees of anatomical
involvement, and it is worth noting that the surgical
procedure is shown in the evaluation of pain, mental
health and quality of life in studies in which the patients
were children and adolescents.
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