1. 2025;28;97-103Accuracy of Imaging in Dynamic Spondylolisthesis: Emerging Strategies and Understanding for Pain Physicians: A Systematic Review
   Systematic Review
   Mihir Jani, MD, Eli Dayon, DO, Nimesha Mehta, DO, Kunal Aggarwal, MD, Joseph D. Fortin, DO, Karoline Zektser, DO, Joshua Lewis, MD, PhD, Marco Lawandy, DO, Ricky Ju, DO, Ugur Yener, MD, Jonathan D. Krystal, MD, Reza Yassari, MD, Alan D. Kaye, MD, PhD, and Sayed E. Wahezi, MD.

BACKGROUND: Chronic low back pain (CLBP) is prevalent, with lumbar spondylolisthesis a common cause of the condition. Spondylolisthesis, the displacement of one vertebra over another, can have various causes. Isthmic and degenerative forms are the most common. Clinicians need to evaluate whether the condition is fixed or dynamic, since dynamic cases may cause vertebral instability and nerve compression, necessitating surgery. Traditional flexion-extension x-rays have been the standard diagnostic tool, but recent studies suggest that alternative imaging methods, such as magnetic resonance imaging or computed tomography, may offer more accurate detection.

OBJECTIVE: Spondylolisthesis, often described as the slipping forward of one of the vertebrae, is a common etiology for CLBP. Generally, spondylolisthesis can be categorized as either stable or unstable. Unstable or dynamic spondylolisthesis is usually diagnosed based on the visualization of sagittal translation of the vertebral body on flexion-extension x-rays. However, it has been reported that flexion-extension x-rays may not be the most reliable method for determining the presence of an unstable spondylolisthesis. The present investigation aimed to identify the extent of the literature that discussed alternative imaging techniques for diagnosing dynamic spondylolisthesis.

STUDY DESIGN: A retrospective systematic review of original research done on spondylolisthesis from 2000 to 2023.

METHODS: A review protocol was followed based on PRISMA guidelines and conducted across 3 databases for relevant articles published between the years 2000 and 2023. Two reviewers screened and characterized the articles independently, and 3 additional reviewers performed full-text analysis and data extraction.

RESULTS: The search yielded 13 articles with differences in origin, study design, sample size, and outcomes. Most of the articles were retrospective studies. Of the 13 articles, 11 showed promising results in utilizing alternative imaging to diagnose dynamic spondylolisthesis.

LIMITATIONS: The lack of a formally registered protocol and potential publication bias were the limitations for this review.

CONCLUSION: The present investigation analyzed the current literature and determined that alternative imaging techniques could adequately diagnose the dynamic instability of the spine. Further research is warranted to establish an in-depth analysis that elucidates the most reliable and sensitive imaging sequence for diagnosing dynamic spondylolisthesis.

KEY WORDS: Spondylolisthesis, dynamic spondylolisthesis, unstable spondylolisthesis, vertebrae