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B
otelho
RV
et
al
.
400
R
ev
A
ssoc
M
ed
B
ras
2014; 60(5):400-403
guidelines in focus
Degenerative spondylolisthesis: surgical treatment
E
spondilolistese
degenerativa
:
tratamento
cirúrgico
Authorship:
Brazilian Society of Neurosurgery; Brazilian Society of Orthopedics and Traumatology
Participants:
Ricardo V. Botelho; Noel O. Foni; Alberto O. Gotfryd; Carlos Fernando P.S. Herrero; Jefferson
Daniel; Robert Meves; Marcelo Luis Mudo; Ricardo S. Simões; Sérgio Zylbersztejn; Wanderley M. Bernardo
Conflict of interest:
no conflict of interest informed.
http://dx.doi.org/10.1590/1806-9282.60.05.004The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standar-
dize procedures to assist the reasoning and decision-making of doctors.
The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, de-
pending on the conditions and the clinical status of each patient.
D
escription
of
the
evidence
collection method
To develop this guideline the following primary and se-
condary electronic databases were consulted: Medline
(1966-2009), Cochrane, Cochrane Central Register of Con-
trolled Trials – Central, Embase (1980-2010) and Lilacs
(1982-2010). The search for evidence came from actual
clinical scenarios and used keywords (MeSH terms) grou-
ped in the following syntax: surgical procedures, opera-
tive, nonsurgical,therapy, lumbosacral region, lumbosa-
cral, degenerative, spondylolisthesis, spondylolisthesis.
The articles were selected after critical evaluation of the
strength of scientific evidence by specialists from the par-
ticipating Medical Associations, and publications of grea-
test strength were used for recommendation. The recom-
mendations were drawn from group discussion. The
entire guideline was reviewed by an independent group
specializing in evidence-based clinical guidelines.
G
rade
of
recommendation
and
strength
of
evidence
A.
Experimental or observational studies of higher con-
sistency.
B.
Experimental or observational studies of lower con-
sistency.
C.
Case reports (non-controlled studies).
D.
Opinions without critical evaluation, based on con-
sensus, physiological studies, or animal models.
O
bjective
This guideline’s target audience comprises general prac-
titioners, rheumatologists, orthopedists, physiatrists, neu-
rologists and neurosurgeons in order to be able to guide
patients with lower back pain and/or sciatic pain resis-
tant to non-operative treatment caused by lumbar dege-
nerative spondylolisthesis regarding the indication for
surgical treatment.
I
ntroduction
Degenerative spondylolisthesis refers to a forward slippage
of a lumbar, with an intact neural arch. Uncommon before
the age of 50 years, it is more common in women and par-
ticularly in blacks, with a male: female ratio of 1:6 (
B
).
1
L4-
-L5 is the most commonly affected level and rarely exceeds
30% of the vertebral width. Degenerative spondylolisthesis
is usually asymptomatic but may be associated with symp-
tomatic stenosis of the lumbar spinal canal. The canal ste-
nosis is the most common cause of back surgery in adults
over 65 years when associated with neurogenic claudication.
However, spinal stenosis is usually asymptomatic. Therefo-
re, clinical radiological correlation is essential for making
decisions (
A
).
2
Surgical treatment with spinal decompres-
sion and stabilization in spondylolisthesis is recommended
when conservative treatment fails (
B
).
3
H
ow
long
should
conservative
treatment
(
non
-
operative
)
be maintained
?
In general, favorable functional outcomes in patients un-
responsive to non-operative treatment are reported in
groups with diverse etiologies for degenerative lumbar
stenosis as well as time of conservative treatment (
C
).
4-6
The time tested in this particular group of patients inclu-
ded in the clinical trial was 12 weeks. Patients treated con-
servatively without success and who underwent surgical
treatment had better progression from a functional point
of view, after 4 years of follow-up (
B
).
7