title: A critical analysis of the literature regarding surgical approach and outcome for adult low-grade isthmic spondylolisthesis.
abstract: OBJECTIVE
  A systematic review of the radiographic and clinical outcomes of adult patients undergoing surgery for low-grade isthmic spondylolisthesis was performed to determine whether conclusions could be made regarding the optimal choice of surgically managing adult low-grade isthmic spondylolisthesis.
  
  
  METHODS
  We tabulated the radiographic and clinical outcomes of patients who underwent a posterior procedure alone, an anterior procedure alone, or a combined anterior and posterior procedure. We also evaluated the influence of covariates such as laminectomy, spinal internal fixation, smoking, and secondary gain issues on these outcomes. Patients were pooled, and a chi analysis was performed to determine the relationship between surgical approach and patient outcome. A covariate analysis was performed to determine the influence of a laminectomy, spinal fixation, smoking, and secondary gain issues on these outcomes.
  
  
  RESULTS
  The available literature consisted primarily of retrospective case series, with only 4 of 34 reports being prospective randomized controlled studies. Patients with combined anterior and posterior procedures were most likely to achieve a solid fusion and a successful clinical outcome. The use of spinal fixation also increased the chance of fusion and successful clinical outcome.
  
  
  CONCLUSIONS
  A pooling of the surgical literature on adult low-grade spondylolisthesis indicates that a combined anterior and posterior procedure most reliably achieves fusion and a successful clinical outcome. The literature, however, is primarily retrospective and heterogeneous with respect to indications for surgery and methods of evaluating outcome, providing a compelling rationale for a prospective randomized controlled trial of the various surgical approaches to this problem.
authors.affiliation: Gowan and Michele Guest Neuroscience Canada Foundation/CIHR, International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, British Columbia, Canada. briankkwon@yahoo.ca
authors.forename: Brian K
authors.initials: BK
authors.lastname: Kwon
authors.forename: Alan S
authors.initials: AS
authors.lastname: Hilibrand
authors.forename: Kelly
authors.initials: K
authors.lastname: Malloy
authors.forename: Paul E
authors.initials: PE
authors.lastname: Savas
authors.forename: Marco T
authors.initials: MT
authors.lastname: Silva
authors.forename: Todd J
authors.initials: TJ
authors.lastname: Albert
authors.forename: Alexander R
authors.initials: AR
authors.lastname: Vaccaro
mesh_terms: D000328:Adult; D000704:Analysis of Variance; D015984:Causality; D006801:Humans; D016268:Internal Fixators / Q000706:statistics & numerical data / Q000639:trends; D007796:Laminectomy / Q000706:statistics & numerical data / Q000639:trends; D008159:Lumbar Vertebrae / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D016239:MEDLINE; D011859:Radiography; D016032:Randomized Controlled Trials as Topic / Q000592:standards; D012189:Retrospective Studies; D012907:Smoking / Q000639:trends; D013123:Spinal Fusion / Q000379:methods / Q000706:statistics & numerical data* / Q000639:trends*; D013168:Spondylolisthesis / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D016896:Treatment Outcome