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Instability
Kevin R. Moore, MD; Jeffrey S. Ross, MD
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Pathology

          • Diagnostic Checklist

            TERMINOLOGY

            • Synonyms

              • Spine instability (SI), segmental instability, abnormal spinal motion, degenerative instability
            • Definitions

              • Loss of spine motion segment stiffness when applied force produces greater displacement than normal with pain/deformity
              • Neoplastic instability: Loss of spinal integrity from neoplastic process associated with movement-related pain, symptomatic or progressive deformity, &/or neural compromise under physiologic loads

            IMAGING

            • General Features

              • Radiographic Findings

                • Fluoroscopic Findings

                  • CT Findings

                    • MR Findings

                      • Imaging Recommendations

                        DIFFERENTIAL DIAGNOSIS

                          PATHOLOGY

                          • General Features

                            • Staging, Grading, & Classification

                              • Gross Pathologic & Surgical Features

                                • Microscopic Features

                                  CLINICAL ISSUES

                                  • Presentation

                                    • Demographics

                                      • Natural History & Prognosis

                                        • Treatment

                                          DIAGNOSTIC CHECKLIST

                                          • Consider

                                            • Image Interpretation Pearls

                                              Selected References

                                              1. Reeves NP et al: Are stability and instability relevant concepts for back pain? J Orthop Sports Phys Ther. 49(6):415-24, 2019
                                              2. Vincent SA et al: The unstable spine: a surgeon's perspective. Semin Ultrasound CT MR. 39(6):618-29, 2018
                                              3. Abbasi Fard S et al: Instability in thoracolumbar trauma: is a new definition warranted? Clin Spine Surg. 30(8):E1046-49, 2017
                                              4. Muto M et al: Neuroimaging of spinal instability. Magn Reson Imaging Clin N Am. 24(3):485-94, 2016
                                              5. Izzo R et al: Biomechanics of the spine. Part I: spinal stability. Eur J Radiol. 82(1):118-26, 2013
                                              6. Izzo R et al: Biomechanics of the spine. Part II: spinal instability. Eur J Radiol. 82(1):127-38, 2013
                                              7. Fourney DR et al: Spinal instability neoplastic score: an analysis of reliability and validity from the spine oncology study group. J Clin Oncol. 29(22):3072-7, 2011
                                              8. Fisher CG et al: A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine (Phila Pa 1976). 35(22):E1221-9, 2010
                                              9. Lall R et al: A review of complications associated with craniocervical fusion surgery. Neurosurgery. 67(5):1396-402; discussion 1402-3, 2010
                                              10. Winegar CD et al: A systematic review of occipital cervical fusion: techniques and outcomes. J Neurosurg Spine. 13(1):5-16, 2010
                                              11. Alamin T et al: Lumbar tumor resections and management. Orthop Clin North Am. 40(1):93-104, vii, 2009
                                              12. Ahmed R et al: Fusions at the craniovertebral junction. Childs Nerv Syst. 24(10):1209-24, 2008
                                              13. Haughton VM et al: Measuring the axial rotation of lumbar vertebrae in vivo with MR imaging. AJNR Am J Neuroradiol. 23(7):1110-6, 2002
                                              14. Kristof RA et al: Degenerative lumbar spondylolisthesis-induced radicular compression: nonfusion-related decompression in selected patients without hypermobility on flexion-extension radiographs. J Neurosurg. 97(3 Suppl):281-6, 2002
                                              15. Kuroki H et al: Clinical results of posterolateral fusion for degenerative lumbar spinal diseases: a follow-up study of more than 10 years. J Orthop Sci. 7(3):317-24, 2002
                                              16. Pitkanen MT et al: Segmental lumbar spine instability at flexion-extension radiography can be predicted by conventional radiography. Clin Radiol. 57(7):632-9, 2002
                                              17. Tay BB et al: Indications, techniques, and complications of lumbar interbody fusion. Semin Neurol. 22(2):221-30, 2002
                                              18. Bendo JA et al: Importance of correlating static and dynamic imaging studies in diagnosing degenerative lumbar spondylolisthesis. Am J Orthop. 30(3):247-50, 2001
                                              19. Chen WJ et al: Surgical treatment of adjacent instability after lumbar spine fusion. Spine. 26(22):E519-24, 2001
                                              20. Nizard RS et al: Radiologic assessment of lumbar intervertebral instability and degenerative spondylolisthesis. Radiol Clin North Am. 39(1):55-71, v-vi, 2001
                                              21. Gibson JN et al: Surgery for degenerative lumbar spondylosis. Cochrane Database Syst Rev. (3):CD001352, 2000
                                              22. Herkowitz HN et al: Management of degenerative disc disease above an L5-S1 segment requiring arthrodesis. Spine. 24(12):1268-70, 1999
                                              23. Mochida J et al: How to stabilize a single level lesion of degenerative lumbar spondylolisthesis. Clin Orthop. (368):126-34, 1999
                                              24. Nakai S et al: Long-term follow-up study of posterior lumbar interbody fusion. J Spinal Disord. 12(4):293-9, 1999
                                              25. Murata M et al: Lumbar disc degeneration and segmental instability: a comparison of magnetic resonance images and plain radiographs of patients with low back pain. Arch Orthop Trauma Surg. 113(6):297-301, 1994
                                              26. Whitecloud TS 3rd et al: Operative treatment of the degenerated segment adjacent to a lumbar fusion. Spine. 19(5):531-6, 1994
                                              27. Abumi K et al: Biomechanical evaluation of lumbar spinal stability after graded facetectomies. Spine. 15(11):1142-7, 1990
                                              28. Boden SD et al: Lumbosacral segmental motion in normal individuals. Have we been measuring instability properly? Spine. 15(6):571-6, 1990
                                              29. Weiler PJ et al: Numerical [corrected] analysis of the load capacity of the human spine fitted with L-rod instrumentation. Spine. 15(12):1285-93, 1990
                                              30. Hayes MA et al: Roentgenographic evaluation of lumbar spine flexion-extension in asymptomatic individuals. Spine. 14(3):327-31, 1989
                                              31. Johnsson KE et al: Postoperative instability after decompression for lumbar spinal stenosis. Spine. 11(2):107-10, 1986
                                              32. Frymoyer JW et al: Segmental instability. Rationale for treatment. Spine. 10(3):280-6, 1985
                                              33. Gertzbein SD et al: Centrode patterns and segmental instability in degenerative disc disease. Spine. 10(3):257-61, 1985
                                              Related Anatomy
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                                              Related Differential Diagnoses
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                                              References
                                              Tables

                                              Tables

                                              KEY FACTS

                                              • Terminology

                                                • Imaging

                                                  • Top Differential Diagnoses

                                                    • Pathology

                                                      • Diagnostic Checklist

                                                        TERMINOLOGY

                                                        • Synonyms

                                                          • Spine instability (SI), segmental instability, abnormal spinal motion, degenerative instability
                                                        • Definitions

                                                          • Loss of spine motion segment stiffness when applied force produces greater displacement than normal with pain/deformity
                                                          • Neoplastic instability: Loss of spinal integrity from neoplastic process associated with movement-related pain, symptomatic or progressive deformity, &/or neural compromise under physiologic loads

                                                        IMAGING

                                                        • General Features

                                                          • Radiographic Findings

                                                            • Fluoroscopic Findings

                                                              • CT Findings

                                                                • MR Findings

                                                                  • Imaging Recommendations

                                                                    DIFFERENTIAL DIAGNOSIS

                                                                      PATHOLOGY

                                                                      • General Features

                                                                        • Staging, Grading, & Classification

                                                                          • Gross Pathologic & Surgical Features

                                                                            • Microscopic Features

                                                                              CLINICAL ISSUES

                                                                              • Presentation

                                                                                • Demographics

                                                                                  • Natural History & Prognosis

                                                                                    • Treatment

                                                                                      DIAGNOSTIC CHECKLIST

                                                                                      • Consider

                                                                                        • Image Interpretation Pearls

                                                                                          Selected References

                                                                                          1. Reeves NP et al: Are stability and instability relevant concepts for back pain? J Orthop Sports Phys Ther. 49(6):415-24, 2019
                                                                                          2. Vincent SA et al: The unstable spine: a surgeon's perspective. Semin Ultrasound CT MR. 39(6):618-29, 2018
                                                                                          3. Abbasi Fard S et al: Instability in thoracolumbar trauma: is a new definition warranted? Clin Spine Surg. 30(8):E1046-49, 2017
                                                                                          4. Muto M et al: Neuroimaging of spinal instability. Magn Reson Imaging Clin N Am. 24(3):485-94, 2016
                                                                                          5. Izzo R et al: Biomechanics of the spine. Part I: spinal stability. Eur J Radiol. 82(1):118-26, 2013
                                                                                          6. Izzo R et al: Biomechanics of the spine. Part II: spinal instability. Eur J Radiol. 82(1):127-38, 2013
                                                                                          7. Fourney DR et al: Spinal instability neoplastic score: an analysis of reliability and validity from the spine oncology study group. J Clin Oncol. 29(22):3072-7, 2011
                                                                                          8. Fisher CG et al: A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine (Phila Pa 1976). 35(22):E1221-9, 2010
                                                                                          9. Lall R et al: A review of complications associated with craniocervical fusion surgery. Neurosurgery. 67(5):1396-402; discussion 1402-3, 2010
                                                                                          10. Winegar CD et al: A systematic review of occipital cervical fusion: techniques and outcomes. J Neurosurg Spine. 13(1):5-16, 2010
                                                                                          11. Alamin T et al: Lumbar tumor resections and management. Orthop Clin North Am. 40(1):93-104, vii, 2009
                                                                                          12. Ahmed R et al: Fusions at the craniovertebral junction. Childs Nerv Syst. 24(10):1209-24, 2008
                                                                                          13. Haughton VM et al: Measuring the axial rotation of lumbar vertebrae in vivo with MR imaging. AJNR Am J Neuroradiol. 23(7):1110-6, 2002
                                                                                          14. Kristof RA et al: Degenerative lumbar spondylolisthesis-induced radicular compression: nonfusion-related decompression in selected patients without hypermobility on flexion-extension radiographs. J Neurosurg. 97(3 Suppl):281-6, 2002
                                                                                          15. Kuroki H et al: Clinical results of posterolateral fusion for degenerative lumbar spinal diseases: a follow-up study of more than 10 years. J Orthop Sci. 7(3):317-24, 2002
                                                                                          16. Pitkanen MT et al: Segmental lumbar spine instability at flexion-extension radiography can be predicted by conventional radiography. Clin Radiol. 57(7):632-9, 2002
                                                                                          17. Tay BB et al: Indications, techniques, and complications of lumbar interbody fusion. Semin Neurol. 22(2):221-30, 2002
                                                                                          18. Bendo JA et al: Importance of correlating static and dynamic imaging studies in diagnosing degenerative lumbar spondylolisthesis. Am J Orthop. 30(3):247-50, 2001
                                                                                          19. Chen WJ et al: Surgical treatment of adjacent instability after lumbar spine fusion. Spine. 26(22):E519-24, 2001
                                                                                          20. Nizard RS et al: Radiologic assessment of lumbar intervertebral instability and degenerative spondylolisthesis. Radiol Clin North Am. 39(1):55-71, v-vi, 2001
                                                                                          21. Gibson JN et al: Surgery for degenerative lumbar spondylosis. Cochrane Database Syst Rev. (3):CD001352, 2000
                                                                                          22. Herkowitz HN et al: Management of degenerative disc disease above an L5-S1 segment requiring arthrodesis. Spine. 24(12):1268-70, 1999
                                                                                          23. Mochida J et al: How to stabilize a single level lesion of degenerative lumbar spondylolisthesis. Clin Orthop. (368):126-34, 1999
                                                                                          24. Nakai S et al: Long-term follow-up study of posterior lumbar interbody fusion. J Spinal Disord. 12(4):293-9, 1999
                                                                                          25. Murata M et al: Lumbar disc degeneration and segmental instability: a comparison of magnetic resonance images and plain radiographs of patients with low back pain. Arch Orthop Trauma Surg. 113(6):297-301, 1994
                                                                                          26. Whitecloud TS 3rd et al: Operative treatment of the degenerated segment adjacent to a lumbar fusion. Spine. 19(5):531-6, 1994
                                                                                          27. Abumi K et al: Biomechanical evaluation of lumbar spinal stability after graded facetectomies. Spine. 15(11):1142-7, 1990
                                                                                          28. Boden SD et al: Lumbosacral segmental motion in normal individuals. Have we been measuring instability properly? Spine. 15(6):571-6, 1990
                                                                                          29. Weiler PJ et al: Numerical [corrected] analysis of the load capacity of the human spine fitted with L-rod instrumentation. Spine. 15(12):1285-93, 1990
                                                                                          30. Hayes MA et al: Roentgenographic evaluation of lumbar spine flexion-extension in asymptomatic individuals. Spine. 14(3):327-31, 1989
                                                                                          31. Johnsson KE et al: Postoperative instability after decompression for lumbar spinal stenosis. Spine. 11(2):107-10, 1986
                                                                                          32. Frymoyer JW et al: Segmental instability. Rationale for treatment. Spine. 10(3):280-6, 1985
                                                                                          33. Gertzbein SD et al: Centrode patterns and segmental instability in degenerative disc disease. Spine. 10(3):257-61, 1985