Surgery for spondylolisthesis is controversial. It is debatable whether a spondylolisthesis should be fused in situ or reduced and fused in the corrected position. In an attempt to address this issue 68 patients who had undergone surgery between 2000 and 2005 for back and leg pain related to a spondylolisthesis with associated spinal stenosis were retrospectively reviewed.

The average age was 53 years. There were 24 male and 44 female patients. A degenerative spondylolisthesis was present in 38 patients while 30 had an isthmic spondylolisthesis. All patients presented with neurogenic back and leg pain that had been present for 6 months. A major neurologic deficit was not present in any patient. The average pre-operative Oswestry score was 42%. Imaging included standard lumbar spine radiographs with dynamic views and MRI. Conservative treatment included pain medication, physiotherapy, nerve root blocks and epidural cortisone injections. A posterior in situ instrumented fusion was performed in 49 patients while 19 underwent reduction and a 360 fusion. A TLIF was used in 11 patients and an ALIF in 8. The average follow-up was 26 months.

Back pain had improved in all patients and the average post-op Oswestry score was 12%. At final follow-up a radiologic fusion was present in all patients. No post-operative neurologic complication was noted in patients who had reduction of the spondylolisthesis. Leg pain persisted in 5 patients (10%) who had posterior in situ fusion while no patient who had a reduction of the spondylolisthesis had residual leg pain. These 5 patients with persistent leg pain underwent removal of the implant and an improvement was noted in 3.

The authors conclude that reduction of the spondylolisthesis with an interbody fusion appears to improve the outcome with regards to neurogenic leg pain. There was no difference in the outcome for back pain.

Over 5 years we gave 84 patients epidural cortisone (80 mg depomedrol and local anaesthesia) for back and/or leg pain due to degenerative disease of the spine.

The mean age of the 35 men and 49 women was 65.2 years (37 to 86). All patients had back pain and 77% had neurogenic leg pain. Spinal radiographs demonstrated degenerative changes, including intervertebral disc space narrowing and/or facet joint arthritis, in 84%. MRI, performed in 80 patients (95%), confirmed degenerative disease of the lumbar spine and demonstrated neural compression in 78 of the 80 (97%). Five patients received a second epidural injection and one a third. Complete resolution of back and/or leg pain occurred in 32 patients (38%), and 34 (40%) had relief for between 1 and 12 months. There was no change in the symptoms of 18 patients (21%). Surgery was undertaken in 17 patients (20%), with seven undergoing spinal decompression alone and 10 decompression and a fusion. After surgery, four of the seven patients who did not have a fusion still had back pain. All 10 of the patients who underwent decompression and fusion had a good outcome. One patient developed an epidural haematoma following the epidural injection.

Epidural steroid injection had a favourable outcome in 78% of our patients, with a low incidence of complications. Patients who failed to respond to the epidural injection did poorly with spinal decompression alone.

The posterior ligament complex (PLC) in the cervical spine comprises the posterior longitudinal ligament, ligamentum flavum and ligamentum nuchae, the latter homologous with the supraspinous and interspinous ligaments at other levels of the spine. In determining instability, evaluation of the PLC is an essential part of the assessment of cervical spine injuries. Disruption of the PLC occurs following flexion injuries, both in compression and in distraction, and following extension injuries with compression. PLC disruption, diagnosed when clinical examination reveals localised posterior spinal tenderness and/or a widened interspinous gap, is confirmed on standard and dynamic flexion-extension radiographs and MRI.

This paper is a retrospective review of 162 patients treated for cervical injuries between 1997 and 2001. There were 83 (51%) distraction flexion, 37 (23%) compression flexion, 18 (11%) compression extension, 17 (10%) vertical compression, six (4%) distraction extension and one (1%) lateral flexion injuries. In 79 patients with pure ligamentous instability, an interspinous stabilisation procedure was performed, using a titanium cable. When associated fractures occurred with PLC disruption, neurologically intact patients were managed conservatively with traction followed by a spinal brace. Patients with a neurological deficit underwent surgery. Using delayed dynamic flexion-extension views and MRI, PLC disruption was diagnosed late in nine flexion distraction injuries without facet dislocation. At follow-up, flexion-extension views showed that all PLC disruptions with associated fractures had stabilised. There were two broken cables in patients who underwent surgery.

Patients with cervical instability following trauma may be treated non-operatively when there are associated fractures, while patients with pure ligamentous instability should undergo fusion. Further, to exclude occult PLC disruption, all cervical injuries should be reviewed on flexion-extension views once the paraspinal muscle spasm has settled.