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Upper lumbar spondylolysis is rare and there are few reports which describe the condition. Three patients with upper lumbar spondyloysis, two of whom underwent surgical treatment, are reviewed. A radiological review of 205 patients with back pain attending a Back Research Clinic revealed three additional patients with symptomatic upper lumbar spondylolysis. clinical diagnosis of this condition is often difficult and the results of operation are unsatisfactory. It is more common among men and trauma appears to play a major role in the production of symptoms.

Planar bone scintigraphy (PBS) and single-photon emission computed tomography (SPECT) were compared in 19 adults with radiographic evidence of spondylolysis and/or spondylolisthesis. SPECT was more sensitive than PBS when used to identify symptomatic patients and sites of "painful" defects in the pars interarticularis. In addition, SPECT allowed more accurate localization than PBS. In 6 patients, spondylolysis or spondylolisthesis was unrelated to low back pain, and SPECT images of the posterior neural arch were normal. The authors conclude that when spondylolysis or spondylolisthesis is the cause of low back pain, pars defects are frequently heralded by increased scintigraphic activity which is best detected and localized by SPECT.

The appearance on magnetic resonance (MR) images of the normal pars interarticularis in 13 patients was reviewed and contrasted with that of the pars in eight patients with spondylolysis. The pars defect usually had an intermediate signal intensity with all pulse sequences; however, this intensity was somewhat variable depending on the exact ratio of cartilage, fat, and fluid within each bone defect. The pars defect was best seen with spin-echo 600/20 (repetition time msec/echo time msec) images. In three cases, out-of-phase images showed the spondylolysis best, because of extension of fat to the borders of the defect. The sagittal view allowed one to separate spondylolysis from the joint space of posterior facets since the orientation of the defects is perpendicular to the facets; thus, a common pitfall encountered with cross-sectional axial imaging techniques is avoided. MR imaging poorly delineated bone fragments around the defect, which may produce nerve root impingement, but revealed other numerous complications that occur with spondylolysis, including spondylolisthesis and herniation of the disk above.

The author reviews the variety of radiological modalities that may be used to investigate spinal disease and then discusses their application in specific disease states.

The authors report 26 cases of surgically treated degenerative spondylolisthesis. Twelve patients complained of permanent uni or bilateral sciatica. All the others had a syndrome of intermittent claudication with pain and paresthaesia. The authors stress once again the highly evocative nature of this syndrome which reflects involvement of the nerve roots in the stenosed lumbar canal. Treatment consisted of lamino-arthrectomy which resulted in the disappearance of symptoms in most of cases. In four cases, vertebral slipping worsened during the post-operative cowise with, in three cases a recurrence of symptoms necessitating a complementary arthrodesis. This risk of increased slipping is a result of the instability created by the arthrectomy, especially when it is bilateral, and has led the authors to widen their indications for routine complementary postero-lateral arthrodesis.

The treatment over the past 12 years of 60 patients with degenerative spondylolisthesis with an intact neural arch is reviewed. The patients averaged 65 years of age, with women outnumbering men by a ratio of 2:1. Symptoms in the lower extremities had been present for 3 months to 10 years, although varying back pain had existed for longer periods. Two-thirds showed signs of motor dysfunction. Sensory alterations and a positive Las ègue's sign could be demonstrated in only one-half of the patients studied. Four of 5 patients developed intermittent neurogenic claudication, with varying evidence of painful radiculopathy. The marked disability caused by claudication contrasted sharply with the lesser neurological changes, and these patients required early surgical decompression. Diagnostic studies included electromyography, plain x-ray films, tomography, computed tomographic scanning, and myelography. The latter outlined a relative stenosis caused by olisthesis as well as arthrotic and spondylotic changes that determined the extent of decompressive operation required. The L-4, L-5 interspace was involved in 56 patients, L-3, L-4 was involved in 2, and L-5, S-1 was involved in 2. The ideal operation with L-4, L-5 olisthesis included complete laminectomy of L-4 and L-5 with unroofing of the lateral recesses and foraminotomy. This more extensive procedure was justified because of the failures encountered in previous patients in whom inadequate decompression had been performed. Among failures, obesity, diabetes, hyperlordosis, and extensive long-standing dysfunction were prominent. The relief of symptoms of intermittent neurogenic claudication was the most gratifying response observed. There was no unusual morbidity.