This narrative review covers the epidemiology, natural history, clinical presentation, imaging evaluation, and full treatment spectrum — nonsurgical and surgical — of adult isthmic spondylolisthesis, synthesizing the evidence to guide management decisions based on grade, symptoms, and patient-specific factors.
When an adult presents with low back or radicular pain and imaging shows a pars defect, start with 3–6 months of flexion-based PT, NSAIDs, and antilordotic bracing before considering surgery — over 75% of grade I–II patients will improve.
If surgery is needed, circumferential fusion offers the best fusion rates, but procedure selection must account for the counterintuitive clinical outcomes data and individual risk-benefit analysis, particularly the neurologic risks of pedicle screw instrumentation and active reduction in high-grade slips.
This narrative review covers the epidemiology, natural history, clinical presentation, imaging evaluation, and full treatment spectrum — nonsurgical and surgical — of adult isthmic spondylolisthesis, synthesizing the evidence to guide management decisions based on grade, symptoms, and patient-specific factors.
When an adult presents with low back or radicular pain and imaging shows a pars defect, start with 3–6 months of flexion-based PT, NSAIDs, and antilordotic bracing before considering surgery — over 75% of grade I–II patients will improve.
If surgery is needed, circumferential fusion offers the best fusion rates, but procedure selection must account for the counterintuitive clinical outcomes data and individual risk-benefit analysis, particularly the neurologic risks of pedicle screw instrumentation and active reduction in high-grade slips.