Current Evidence Regarding the Treatment of Pediatric Lumbar Spondylolisthesis: A Report From the Scoliosis Research Society Evidence Based Medicine Committee.

STUDY DESIGN: Structured literature review.

OBJECTIVES: The Scoliosis Research Society requested an assessment of the current state of peer-reviewed evidence regarding pediatric lumbar spondylolisthesis to identify what is known and what research remains essential to further understanding.

SUMMARY OF BACKGROUND DATA: Pediatric lumbar spondylolisthesis is common, yet no formal synthesis of the published literature regarding treatment has been previously performed.

METHODS: A comprehensive literature search was performed. From 6600 initial citations with abstract, 663 articles underwent full-text review. The best available evidence regarding surgical and medical/interventional treatment was provided by 51 studies. None of the studies were graded Level I or II evidence. Eighteen of the studies were Level III, representing the current best available evidence. Thirty-three of the studies were Level IV.

RESULTS: Although studies suggest a benign course for "low grade" (<50% slip) isthmic spondylolisthesis, extensive literature suggests that a substantial number of patients present for treatment with pain and activity limitations. Pain resolution and return to activity is common with both medical/interventional and operative treatment. The role of medical/interventional bracing is not well established. Uninstrumented posterolateral fusion has been reported to produce good clinical results, but concerns regarding nonunion exist. Risk of slip progression is a specific concern in the "high grade" or dysplastic type. Although medical/interventional observation has been reported to be reasonable in a small series of asymptomatic high-grade slip patients, surgical treatment is commonly recommended to prevent progression. There is Level III evidence that instrumentation and reduction lowers the risk of nonunion, and that circumferential fusion is superior to posterior-only or anterior-only fusion. There is Level III evidence that patients with a higher slip angle are more likely to fail medical/interventional treatment of high-grade spondylolisthesis.

CONCLUSIONS: The current "best available" evidence to guide the treatment of pediatric spondylolisthesis is presented.

LEVEL OF EVIDENCE: Level III; review of Level III studies.