|Year : 2021 | Volume
| Issue : 1 | Page : 10-17
Classification of spondylolisthesis: Current concepts
Sahil Batra, Bhavuk Garg
Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), New Delhi, India
|Date of Submission||30-Jul-2020|
|Date of Decision||26-Aug-2020|
|Date of Acceptance||19-Oct-2020|
|Date of Web Publication||28-Jan-2021|
Dr. Sahil Batra
Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), New Delhi.
Source of Support: None, Conflict of Interest: None
The restoration of global sagittal balance has become the keystone over the past decade. Various classification systems have been proposed for lumbosacral spondylolisthesis. This article describes the evolution, validation, and usage of these classification systems in the clinical setting in the current scenario.
Keywords: Lumbo-sacral kyphosis, myerding grading, SDSG classification, spondylolisthesis, Wiltse classification
|How to cite this article:|
Batra S, Garg B. Classification of spondylolisthesis: Current concepts. Indian Spine J 2021;4:10-7
| Introduction|| |
Spondylolisthesis is a Greek word in which “spondylos” means vertebrae and “oliothesis” refers to slippage or dislocation. The term “Spondylolisthesis” was first used by Kilian in Lonstein et al. Spondylolisthesis is characterized by a variety of causes, which include degenerative, isthmic, trauma, tumor, or congenital dysplasia. The reported incidence of spondylolisthesis is 4% to 6% in children, with isthmic being the most common variety, occurring at L5-S1.,, Degenerative spondylolisthesis is most commonly seen in the elderly, with an incidence up to 5–10%, and it occurs commonly at L4-L5 followed by L5-S1.,, Clinical presentation ranges from lower back pain to unilateral or bilateral radiculopathy depending on the severity of disease. Various classification systems have been used based on slip grade, etiology, dysplasia, and spino-pelvic parameters to measure spondylolisthesis and observe its progression.
| Evolution|| |
In 1932, Meyerding developed the first grading of spondylolisthesis, which included four types based on the degree of slippage of one vertebral body over another. A slippage of 0–25% was defined as Grade I, 25 to 50% as Grade II, 50–75% as Grade III, and 75–100% as Grade IV. The degree of slip is measured on a standing, neutral radiograph of the lumbar spine.
The percentage of slippage is measured by drawing a line through the posterior border of the superior and inferior vertebral body, and the translation of the superior vertebral body is measured as a percentage of the distance between these two lines. To the original Meyerding classification, a Grade V was introduced, which indicates a slippage of more than 100%; a condition known as spondyloptosis [Figure 1].
|Figure 1: Grade 3 spondylolisthesis (Myerding grading) and LSK measured as Dubousset-Lumbosacral angle (Dub-LSA)|
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Dysplastic spondylolisthesis is characterized by the presence of kyphosis, in addition to translation; hence, Newman proposed classification for higher grades (Grade III, IV, and V), which was further modified by Dewald et al. In this classification, the dome and anterior surface of sacrum is divided into ten parts. The first value is calculated on the basis of location of the posterior–inferior corner of the L5 vertebrae with respect to the sacral dome, and the second value is calculated on the basis of location of the anterior–inferior corner of the L5 vertebrae with respect to the anterior surface of the sacrum. Both values quantify the amount of anterior roll of L5 over S1 [Figure 2].
|Figure 2: High-grade spondylolisthesis showing Newman grading suggesting anterior roll of L5 over S1|
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| Wiltse Classification|| |
In 1976, Wiltse proposed a classification based on anatomic and etiology factors. Six types are described:
- Type I: Congenital dysplasia
It includes congenital dysplasia of the sacrum vertebrae (S1) or a neural arch of L5. The presence of the sacral dome allows L5 to slip anteriorly.
There is a defect in the pars intercularis and it occurs most commonly in children. It is subdivided into three types:
- IIA: Pars lysis (most common) [Figure 3]
- IIB: Pars elongation
- IIC: Acute pars fracture
- Type III: Degenerative
It is seen most commonly in older age groups due to stress loading, and it leads to segmental instability [Figure 4].
|Figure 4: Degenerative spondylolisthesis showing Facet arthropathy, grade 1 spondylolisthesis L4-5|
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There is a fracture of hook (posterior elements) other than pars.
- Type V: Neoplastic (systemic/local)
- Type VI: Iatrogenic
| Marchetti and Bartolozzi Classification|| |
In 1982, Marchetti and Bartolozzi introduced another classification to distinguish between the developmental and acquired form of spondylolisthesis [Table 1].,,
Developmental spondylolisthesis is further subdivided into two major subtypes: high and low dysplasia, depending on the severity of bony dysplasia at the lumbo-sacral region and the progression of further slippage.
High dysplasia is characterized by junctional kyphosis, trapezoidal L5 vertebral body, anomaly of the superior end plate of S1 and dysplastic posterior elements of L5 and S1 [Figure 5]. Low dysplasia includes minimal junctional kyphosis, a rectangular L5 vertebral body, absence of sacral doming, and a nearly normal transverse process. Both high and low dysplasias were further divided on the basis of the presence or absence of elongation and lysis.
|Figure 5: High-grade spondylolisthesis characterized by junctional kyphosis, sacral dome, trapezoidal L5 vertebral body, and inverted Naploean hat sign|
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Acquired spondylolisthesis is further subdivided into traumatic, degenerative, neoplastic, and postsurgical (iatrogenic).
| Current Concepts on Sagittal Balance|| |
A human being is always under the constraint of gravity. The bipedal stance exhibits a close relationship between the pelvis and spine, as described by Dubousset in his cone of economy concept. The pelvis is often described as the first vertebrae, and the entire vertebral column is positioned onto this base. The frontal balance is defined with the vertebral column being vertical and it has an axis that passes through the middle of the sacrum. Sagittal balance is a more complex parameter to be defined, and it depends on the center of the line of gravity and the resultant line of gravity. In a normal well-aligned and balanced spine, the line of gravity projects itself onto the ground marked by feet and the center of gravity is marked on this line in front of the S2 vertebrae.,
The alteration in the sagittal plane leads to abnormal biomechanical stresses at the lumbo-sacral junction. The body uses a compensatory mechanism to maintain upright posture. In patients with high pelvic incidence (PI), the risk of progression appears to be more than in low to normal PI. The compensatory mechanism begins at the segmental level, with an increase in lumbar lordosis to keep the center of gravity and enable the plumb line to fall behind the femoral heads. After attaining maximum permissible lumbar lordosis, compensation occurs at the regional level, leading to retroversion of the pelvis. Pelvic retroversion translates into extension at the hip joint. This compensation is limited by an anatomical parameter defined as PI, which is a constant for each individual. Further compensation occurs by either leaning forward or flexing the knee joint. Along with all these mechanisms, a decrease in thoracic kyphosis and cervical hyperlordosis also takes place. All the progressive compensatory mechanisms lead to positive sagittal balance/ unbalanced spine.,
| Spinal Deformity Study Group Classification (SDSG)|| |
In 2006, Mac-Thiong et al. developed a comprehensive classification on spondylolisthesis, which included parameters such as slip grade, spino-pelvic alignment, and bony dysplasia. Eight types were devised in this classification. Due to difficulty in assessing bony dysplasia on the radiograph and with fair inter-rate reliability found in the initial studies; bony dysplasia was removed from the classification. In 2009, the Spinal Deformity Study Group (SDSG) proposed six types of spondylolisthesis in the newer classification system. This classification is not applicable for degenerative spondylolisthesis or L4-L5 pathology.
The first step of this classification includes Meyerding grading and thereby quantifies the spondylolisthesis as low grade (Grade I and II) and high grade (Grade III, IV, and V). The second step includes assessment of the spino-pelvic alignment, which comprises global sagittal balance (balanced spine) and sacro-pelvic alignment (sacral slope, pelvic tilt, and PI) [Figure 6].
|Figure 6: High-grade spondylolisthesis showing sacral slope, pelvic tilt, and PI|
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Balanced spine is defined as a plumb line from C7 that falls at or behind femoral heads. If this plumb line falls anterior to femoral heads; it is known as unbalanced spine. Sacro-pelvic alignment is defined by sacral slope and pelvic tilt. High sacral slope/ low pelvic tilt denotes balanced sacro-pelvic alignment, whereas low sacral slope/ high pelvic tilt denotes unbalanced sacro-pelvic alignment.
Low-grade spondylolisthesis was divided into three types on the basis of PI:
- Type I: < 45° PI (Low)
- Type II: 45–60° PI (Normal)
- Type III: > 60° PI (High)
The development of spondylolisthesis in Type 1 is due to the “nut cracker” effect, as there is an impact on posterior elements from L4 to S1 during extension.
High-grade spondylolisthesis was divided into three types on the basis of spino-pelvic alignment, and they are seen to have a PI more than 60°.
- Type IV: Balanced spine and balanced sacro-pelvic alignment
- Type V: Balanced spine and unbalanced sacro-pelvic alignment
- Type VI: Unbalanced spine and unbalanced spino-pelvic alignment
Type V and VI come under the retroverted pelvis, as they have unbalanced sacro-pelvic alignment, which means low sacral slope/ high pelvic tilt.
| Importance of Lumbo-Sacral Kyphosis (LSK)|| |
Spondylolistheis is a complex deformity and lumbo-sacral kyphosis (LSK) is a major component of this deformity. In high-grade spondylolisthesis, rotational deformity at L5 level can have a significant impact on quality of life. The correction of LSK was considered an important aspect in the surgical management of spondylolisthesis; it has been shown to correlate with a decrease in the physical component score, especially in high-grade spondylolisthesis, and also improves overall spine biomechanics., LSK acts as an independent parameter affecting the quality of life in patients with spondylolisthesis.
The various methods that are used to measure LSK are slip angle (SA), popularized by Boxal et al., lumbosacral joint angle (LSJA) by Wiltse and Winter, and lumbosacral angle (LSA) by the SDSG group. Dubousset introduced lumbosacral angle (Dub-LSA) and proposed the correction of this angle to 100 ͦ to prevent the failure of surgical treatment. All these parameters provide good intra–interobserver reliability.
The SA is measured between the inferior end plate of L5 and a line perpendicular to the posterior aspect of S1. The LSA is measured between the superior border of L5 and the superior border of S1 in dysplastic types. Dub-LSA is measured between the superior end plate of L5 and the posterior border of S1; thus, it is not dependent on the inferior end plate of L5, which becomes dysplastic with higher slippage and also leads to remodeling of S1 vertebrae. Therefore, LSK should be included in the planning of patients with spondylolisthesis [Figure 1].
The SDSG group has subdivided Type 5 into two types on the basis of Dub-LSA.
- Type VA: >80° Dub-LSA
- Type VB: <80° Dub-LSA
The lesser the amount of Dub-LSA; the worse is the prognosis.
| Role in Management|| |
The conventional treatment plan in spondylolisthesis is based on slip grade. Surgical treatment is planned for low-grade spondylolisthesis when the conservative treatment fails, and it is offered in all high-grade spondylolisthesis. Apart from slip grade, evidence suggests that sagittal spino-pelvic balance plays a key role in the management [Figure 7]A and [B] and also evidence from various studies suggested the role of the direct relationship between health-related quality of life and global sagittal balance in patients with spinal deformity.,
|Figure 7: (A) Preoperative radiograph showing spondylolisthesis with unbalanced spine and pelvis. (B) Postoperative radiograph after posterior instrumentation showing balanced spine and pelvis|
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The SDSG classification recommends no reduction in Type IV, attempted reduction in Type V, and successful reduction and restoration of spino-pelvic alignment in Type VI as it has been seen that the restoration of sagittal parameters leads to improvement in health-related quality of life.,,
| Degenerative Spondylolisthesis Classification|| |
None of the systems of classification mentioned earlier relates to the descriptive analysis of degenerative spondylolisthesis, the most common type seen in the elderly age group. It was described as an entity in Wiltse classification. A translation of not more than 30% is seen in degenerative spondylolisthesis., Meyerding grading does not take into account segmental kyphosis and disc height, which are directly related to clinical outcomes in degenerative spondylolisthesis. So in 2014, two different classification systems were proposed for degenerative spondylolisthesis: French and CARDS.,
| French Classification|| |
Gille et al. proposed a new classification system for degenerative spondylolisthesis with lumbar canal stenosis, which was further revised in 2017., According to the authors, three types were described. The parameters taken into account were sagittal vertical axis, segmental lordosis, lumbar lordosis (LL), pelvic tilt, and PI. All the parameters were measured in the standing lateral radiograph of the whole spine. The rationale behind this classification is the correction of global spinal alignment, which is also needed for the treatment of Type 2 and 3 degenerative spondylolisthesis.
- Type 1: PI-LL <10 ͦ
- IA: Preserved segmental lordosis >5 ͦ
- IB: Altered segmental lordosis <5 ͦ
- Type 2: PI-LL >10 ͦ
- 2A: Preserved global alignment without pelvic compensation, Pelvic Tilt <25 ͦ
- 2B: Preserved global alignment with pelvic compensation, Pelvic Tilt >25 ͦ
- Type 3: Altered sagittal vertical axis (>40 mm)
| CARDS Classification|| |
This classification included three radiographic parameters and one clinical variable. The radiographic parameters were disc collapse, segmental kyphosis, and translation. The clinical modifier was leg pain. Four types were described:
- Type A: Advanced disc collapse without kyphosis
- Type B: Preservation of disc space partially with translation less than 5 mm
- Type C: Preservation of disc space partially with translation more than 5 mm
- Type D: Segmental kyphosis
The clinical modifier was leg pain: 0, no leg pain; 1, unilateral leg pain; 2, bilateral leg pain.
The advantage of CARDS classification is that it is easier to use and has better reliability, but it does not take into account global sagittal alignment.
| Validation and Limitation|| |
Classification systems are developed to impart knowledge; to communicate, guide treatment, research purpose; and to prognosticate the treatment. Meyerding classification is very reliable and has very less interobserver variation, but it is not a useful tool to predict disease progression. The symptoms do not correspond to the severity of the slip. Wiltse classification is a descriptive type of classification but it is unable to provide any information on severity and prognosis of the disease. The Marchetti and Bartolozzi classification system categorizes high and low dysplasia, but it is not able to define rigid criteria to distinguish between the two. This classification is useful in terms of predicting prognosis and treatment, but it lacks the ability to predict the progression of disease. None of the classification systems mentioned earlier was helpful for aiding in the surgical decision of spondylolisthesis, [Table 2].
|Table 2: Comparative analysis of classification system of spondylolisthesis|
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Classification by Mac-Thiong et al. and the SDSG was organized into an increasing severity of spondylolisthesis to guide in surgical planning., Studies had shown good reliability while applying this classification, with disagreement ranges from 12.5% to 25%, respectively., The disagreement was more for low-grade spondylolisthesis, as the range of PI is very narrow [45°–60°] and in cases with dysplastic spondylolisthesis as the presence of sacral dome makes it difficult to identify anterior and posterior borders of the sacrum.,
| Conclusion|| |
The classification by the SDSG seems to be promising; however, we still lack studies with a long-term follow-up so a word of caution needs to be applied when using these classification systems to guide surgical treatment.
Compliance with ethical standards
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/ or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Financial support and sponsorship
This study does not receive any funding of any nature.
Conflict of interest
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2]