• North American Spine Society (NASS). Diagnosis and treatment of degenerative lumbar spondylolisthesis. Burr Ridge (IL): North American Spine Society (NASS); 2008. 133 p. [191 references]

This is the current release of the guideline.

The grades of recommendations (A-C, I) and levels of evidence (I-V) are defined at the end of the Major Recommendations field.

Recommendations for Diagnosis and Treatment of Degenerative Lumbar Spondylolisthesis

1. Diagnosis and Imaging

   What are the most appropriate historical and physical examination findings consistent with the diagnosis of degenerative lumbar spondylolisthesis?

   Obtaining an accurate history and physical examination is essential to the formulation of the appropriate clinical questions to guide the physician in developing a plan for the treatment of patients with degenerative lumbar spondylolisthesis.

   In older patients presenting with radiculopathy and neurogenic intermittent claudication, with or without back pain, a diagnosis of degenerative lumbar spondylolisthesis should be considered.

   Grade of Recommendation: B

   Diagnosing Spondylolisthesis with Imaging

   What are the most appropriate diagnostic tests for degenerative lumbar spondylolisthesis?

   The most appropriate, noninvasive test for detecting degenerative lumbar spondylolisthesis is the lateral radiograph.

   Grade of Recommendation: B

   The most appropriate, noninvasive test for imaging the stenosis accompanying degenerative lumbar spondylolisthesis is the magnetic resonance imaging (MRI).

   Plain myelography or computed tomography (CT) myelography are useful studies to assess spinal stenosis in patients with degenerative lumbar spondylolisthesis.

   Grade of Recommendation: B

   CT is a useful noninvasive study in patients who have a contraindication to MRI, for whom MRI findings are inconclusive or for whom there is a poor correlation between symptoms and MRI findings, and in whom CT myelogram is deemed inappropriate.

2. Outcome Measures for Medical/Interventional and Surgical Treatment

   What are the appropriate outcome measures for the treatment of degenerative lumbar spondylolisthesis?

   The Zurich Claudication Questionnaire (ZCQ)/Swiss Spinal Stenosis Questionnaire (SSS), Oswestry Disability Index (ODI), Likert Five-Point Pain Scale and 36-Item Short Form Health Survey (SF-36) are appropriate measures for assessing treatment of degenerative lumbar spondylolisthesis.

   Grade of Recommendation: A

   Note: The Zurich Claudication Questionnaire (ZCQ) represents an evolution of Swiss Spinal Stenosis Questionnaire (SSS). Conclusions made about either questionnaire have a high likelihood of being applicable to the other.

   The Japanese Orthopedic Association (JOA) Score and the calculated Recovery Rate may be useful in assessing outcome in degenerative lumbar spondylolisthesis.

   Grade of Recommendation: B

   The Shuttle Walking Test (SWT), Oxford Claudication Score (OCS), Low Back Pain Bothersome Index and Stenosis Bothersome Index are potential outcome measures in studying degenerative lumbar spondylolisthesis.

   Grade of Recommendation: I (Insufficient Evidence)

3. Medical and Interventional Treatment

   Medical/interventional treatment for degenerative lumbar spondylolisthesis when the radicular symptoms of stenosis predominate, most logically should be similar to treatment for symptomatic degenerative lumbar spinal stenosis.

4. Surgical Treatment

   Do surgical treatments improve outcomes in the treatment of degenerative lumbar spondylolisthesis compared to the natural history of the disease?

   Surgery is recommended for treatment of patients with symptomatic spinal stenosis associated with low grade degenerative spondylolisthesis whose symptoms have been recalcitrant to a trial of medical/interventional treatment.

   Grade of Recommendation: B

   Does surgical decompression alone improve surgical outcomes in the treatment of degenerative lumbar spondylolisthesis compared to medical/interventional treatment alone or the natural history of the disease?

   Direct surgical decompression is recommended for treatment of patients with symptomatic spinal stenosis associated with low grade degenerative lumbar spondylolisthesis whose symptoms have been recalcitrant to a trial of medical/interventional treatment.

   Grade of Recommendation: I (Insufficient Evidence)

   Indirect surgical decompression is recommended for treatment of patients with symptomatic spinal stenosis associated with low grade degenerative lumbar spondylolisthesis whose symptoms have been recalcitrant to a trial of medical/interventional treatment.

   Grade of Recommendation: I (Insufficient Evidence)

   Does the addition of lumbar fusion, with or without instrumentation, to surgical decompression improve surgical outcomes in the treatment of degenerative lumbar spondylolisthesis compared to treatment by decompression alone?

   Surgical decompression with fusion is recommended for the treatment of patients with symptomatic spinal stenosis and degenerative lumbar spondylolisthesis to improve clinical outcomes compared with decompression alone.

   Grade of Recommendation: B

   Does the addition of instrumentation to decompression and fusion for degenerative lumbar spondylolisthesis improve surgical outcomes compared with decompression and fusion alone?

   The addition of instrumentation is recommended to improve fusion rates in patients with symptomatic spinal stenosis and degenerative lumbar spondylolisthesis.

   Grade of Recommendation: B

   The addition of instrumentation is not recommended to improve clinical outcomes for the treatment of patients with symptomatic spinal stenosis and degenerative lumbar spondylolisthesis.

   Grade of Recommendation: B

   How do outcomes of decompression with posterolateral fusion compare with those for 360° fusion in the treatment of degenerative lumbar spondylolisthesis?

   Because of the paucity of literature addressing this question, the work group was unable to generate a recommendation to answer this question.

   What is the role of reduction (deliberate attempt to reduce via surgical technique) with fusion in the treatment of degenerative lumbar spondylolisthesis?

   Reduction with fusion and internal fixation of patients with low grade degenerative lumbar spondylolisthesis is not recommended to improve clinical outcomes.

   Grade of Recommendation: I (Insufficient Evidence)

   What is the long-term result (four+ years) of surgical management of degenerative lumbar spondylolisthesis?

   Decompression and fusion is recommended as a means to provide satisfactory long-term results for the treatment of patients with symptomatic spinal stenosis and degenerative lumbar spondylolisthesis.

   Grade of Recommendation: C

Definitions:

Grades of Recommendation for Summaries or Reviews of Studies

A. Good evidence (Level I Studies with consistent finding) for or against recommending intervention.

B. Fair evidence (Level II or III Studies with consistent findings) for or against recommending intervention.

C. Poor quality evidence (Level IV or V Studies) for or against recommending intervention.

I. Insufficient or conflicting evidence not allowing a recommendation for or against intervention.

Levels of Evidence for Primary Research Question¹

RCT = randomized controlled trial

¹ A complete assessment of quality of individual studies requires critical appraisal of all aspects of the study design.

² A combination of results from two or more prior studies.

³ Studies provided consistent results.

⁴ Study was started before the first patient enrolled.

⁵ Patients treated one way (e.g., cemented hip arthroplasty) compared with a group of patients treated in another way (e.g., uncemented hip arthroplasty) at the same institution.

⁶ The study was started after the first patient enrolled.

⁷ Patients identified for the study based on their outcome, called "cases" (e.g., failed total arthroplasty) are compared to those who did not have outcome, called "controls" (e.g., successful total hip arthroplasty).

⁸ Patients treated one way with no comparison group of patients treated in another way.

None provided

The type of supporting evidence is identified and graded for most of the recommendations (see "Major Recommendations" field).

• North American Spine Society (NASS). Diagnosis and treatment of degenerative lumbar spondylolisthesis. Burr Ridge (IL): North American Spine Society (NASS); 2008. 133 p. [191 references]

Not applicable: The guideline was not adapted from another source.

2008

North American Spine Society - Medical Specialty Society

North American Spine Society (NASS)

North American Spine Society (NASS) Evidence-Based Guideline Development Committee

Committee Members: William C. Watters III, MD, Committee Chair; Christopher Bono, MD, Surgical Treatment Chair; Thomas Gilbert, MD, Diagnosis/Imaging Chair; D. Scott Kreiner, MD, Natural History Chair; Daniel Mazanec, MD, Medical/Interventional Treatment Chair; William O. Shaffer, MD, Outcome Measures Chair; Jamie Baisden, MD;  John Easa, MD; Robert Fernand, MD; Gary Ghiselli, MD; Michael Heggeness, MD, PhD; Richard Mendel, MD; Conor O'Neill, MD; Charles Reitman, MD; Daniel Resnick, MD; Jeffrey Summers, MD; Reuben Timmons, MD; John Toton, MD

All participants involved in guideline development have disclosed potential conflicts of interest to their colleagues, and their potential conflicts have been documented for future reference. They will not be published in any guideline, but kept on file at North American Spine Society (NASS) for reference, if needed. Participants have been asked to update their disclosures regularly throughout the guideline development process.

This is the current release of the guideline.

None available

None available

This NGC summary was completed by ECRI Institute on September 5, 2008. The information was verified by the guideline developer on September 8, 2008.

Full-text guidelines can only be acquired through the North American Spine Society (NASS). Questions regarding use and reproduction should be directed to NASS, attention Belinda Duszynski, Research Manager.