Authors: Che Chung Justin Lin, Ewa Zuzanna Krzyż, Sung Huang Laurent Tsai, Ying-Chih Wang, Chia-Wei Chang, Tung Yi Lin, Tsai Sheng Fu
Categories: Clinical Studies, Isthmic spondylolisthesis, Chat GPT, NASS guidelines, Low back pain, Artificial intelligence in healthcare, Spine
Source: North American Spine Society Journal
Authors: Che Chung Justin Lin, Ewa Zuzanna Krzyż, Sung Huang Laurent Tsai, Ying-Chih Wang, Chia-Wei Chang, Tung Yi Lin, Tsai Sheng Fu
Isthmic spondylolisthesis is a prevalent condition often diagnosed in adults, especially those with low back pain. The main objective of this study was to evaluate the clinical viability of ChatGPT 3.5 and 4.0 by assessing its capacity to produce recommendations consistent with NASS's Evidence-based Clinical Guidelines for adult isthmic spondylolisthesis.
To achieve the purpose of this study, we used the 2014 NASS Evidence-Based Clinical Guideline for Multidisciplinary Spine Care and presented its 31 questions to ChatGPT 3.5 and ChatGPT 4.0 separately, evaluating their responses for appropriateness and consistency with the guidelines.
ChatGPT 3.5 and ChatGPT 4.0 demonstrated concordance rates with the NASS guidelines of 45% and 42%, respectively, with ChatGPT 3.5 showing higher accuracy (91%) for questions with definitive recommendations and both versions showing lower concordance (20%) for questions with no direct recommendations.
Future enhancements should focus on enabling ChatGPT to better reflect the latest evidence and clinical complexities, especially concerning issues that involve medical terms.
Isthmic spondylolisthesis is a prevalent condition often diagnosed in adults, especially those with low back pain [1]. This condition occurs when a vertebral body moves forward relative to the one below it, due to an issue with the pars interarticularis [2]. It has been shown that spondylolysis affects 6% of the general adult population [3]. For spine surgeons to provide effective patient care, they must navigate complex decisions regarding treatment options and management, which can pose significant challenges.
To enhance the understanding of diagnosing and treating isthmic spondylolisthesis in adult patients, in the year of 2014, the Adult Isthmic Spondylolisthesis Work Group of the NASS Evidence-Based Clinical Guideline Development Committee formulated an evidence-based clinical guideline on this matter [4]. The guideline aims to represent current treatment concepts for symptomatic isthmic spondylolisthesis, based on the highest quality clinical literature available as of June 2013 [5]. Currently, this is the most recent certified evidence-based guideline for managing isthmus spondylolisthesis in the adult population.
In recent years, the incorporation of artificial intelligence (AI) technologies has become more widespread across various fields, driving significant changes in how research is performed and how knowledge is produced. GPT is an artificial intelligence (AI) model created by OpenAI, specifically designed to produce text that resembles human writing [6]. Additionally, ChatGPT is a frequently used tools, especially by the those, who are not specialized in the healthcare fields, to gain a medical knowledge. ChatGPT is a sophisticated language model that utilizes deep learning methods to generate human-like responses to natural language inputs [7]. The systematic review, which encompassed 118 articles, concluded that ChatGPT can assist with patient inquiries, note-taking, decision-making, trial enrollment, data management, decision support, research assistance, and patient education. Additionally, it can function as a ``clinical assistant'' and aid in research and scholarly writing [8].
GPT 3.5, trained on datasets up to mid-2021, demonstrated robust performance in general-purpose language tasks but faced limitations in reasoning, multilingual processing, and handling complex queries [9]. In contrast, GPT 4 was developed with an expanded dataset and enhanced architecture, offering notable improvements in logical reasoning, critical thinking, and multilingual understanding. Additionally, GPT 4 incorporates reinforced safety mechanisms and ethical considerations, making it more reliable for nuanced and domain-specific tasks [10]. Despite these advancements, both models share limitations, such as the lack of real-time knowledge and occasional inaccuracies, underscoring the ongoing need for refinement in artificial intelligence systems [9,10].
The objective of this study was to evaluate the clinical viability of ChatGPT 3.5 and 4.0 by assessing its capacity to produce recommendations consistent with NASS's Evidence-based Clinical Guidelines for adult isthmic spondylolisthesis.
We used a NASS Evidence-Based Clinical Guideline for Multidisciplinary Spine Care—Diagnosis and Treatment of Adult Isthmic Spondylolisthesis that was published in 2014 [4]. The guidelines include 31 questions from six different categories—definition and natural history, diagnosis and imaging, outcome measures for medical/interventional and surgical treatment, medical and interventional treatment, surgical treatment, value of spine care.
We presented those questions to the ChatGPT 3.5 and ChatGPT 4.0 separately. The answers were recorded verbatim and summarized. If ChatGPT provided its own summary, we evaluated whether it offered reasonable insight into the selected question. If it did, we used the summary provided by ChatGPT; if not, we created our own summary based on ChatGPT's response.
After collecting all the answers from the guidelines, ChatGPT 3.5, and ChatGPT 4.0, we evaluated the responses provided by both versions of ChatGPT for their appropriateness and consistency with the guidelines. Two independent reviewers specialized in spine care graded these responses as either “concordant” or “nonconcordant.” We assigned these grades separately for the answers from ChatGPT 3.5 and ChatGPT 4.0. When ChatGPT generated responses that included all major points from the NASS guidelines, we gave a “concordant” grade; otherwise, we assigned a “nonconcordant” grade. For each grade given, researchers explained their decision by providing a brief explanation. If any disagreements occur all researchers discussed them during meetings.
We used descriptive statistics (frequency, percentage) to compare the concordance rates between ChatGPT 3.5 and ChatGPT 4.0 across different categories.
ChatGPT 3.5 answered 14 (45%) of the 31 total clinical questions in concordance with the NASS guidelines (Table 1). The concordance within each question category was as It answered the one question on “Definitions and Natural History” (2/2, 100%) in agreement with NASS. For “Diagnosis and Imaging” questions, ChatGPT 3.5 exhibited concordance with NASS 80% of the time, which accounted for 4 out of 5 total questions in this category. ChatGPT 3.5 was concordant with 54% of the recommendations in the “Surgical Treatment” (7/13) category. The ChatGPT failed to concordantly answer any questions within the “Outcome Measures for Medical Intervention and Surgical Treatment” (1/1,100%) and “Value of Spine Care” (0/3, 0%) categories.Table 1ChatGPT 3.5’s Cumulative performance when generating clinical guidelines.Table 1ConcordantChatGPT 3.5ChatGPT 4.0All guidelines, n (%)14/31 (45%)13/31 (42%)Definition and Natural History, n (%)2/2 (100%)2/2 (100%)Diagnosis and Imaging, n (%)4/5 (80%)4/5 (80%)Outcome Measures for Medical/Interventional and Surgical Treatment, n (%)1/1 (100%)1/1 (100%)Medical and Interventional Treatment, n (%)0/7 (0%)0/7 (0%)Surgical Treatment, n (%)7/13 (54%)6/13 (46%)Value of Spine Care, n (%)0/3 (0%)0/3 (0%)
When assessing the model's performance in answering questions for which NASS offered a definitive recommendation, ChatGPT 3.5 was highly accurate with a concordance of 91% (10/11) (Table 2). Conversely, ChatGPT 3.5’s concordance dropped to 20% when answering clinical questions for which the guidelines refrained from providing a direct recommendation given either the paucity of literature or conflicting evidence (4/20) (Table 3).Table 2ChatGPT's performance compared to guidelines with clearly indicated NASS recommendations.Table 2ConcordantChatGPT 3.5ChatGPT 4.0All guidelines, n (%)10/11 (91%)9/11 (82%)Definition and Natural History, n (%)2/2 (100%)2/2 (100%)Diagnosis and Imaging, n (%)4/4 (100%)4/4 (100%)Outcome Measures for Medical/Interventional and Surgical Treatment, n (%)0/0 (0%)0/0 (0%)Medical and Interventional Treatment, n (%)0/0 (0%)0/0 (0%)Surgical Treatment, n (%)4/5 (80%)3/5 (60%)Value of Spine Care, n (%)0/0 (0%)0/0 (0%)Table 3ChatGPT's performance compared to guidelines in which NASS specified the lack of sufficient evidence.Table 3ConcordantChatGPT 3.5ChatGPT 4.0All guidelines, n (%)4/20 (20%)4/20 (20%)Definition and Natural History, n (%)0/0 (0%)0/0 (0%)Diagnosis and Imaging, n (%)0/1 (0%)0/1 (0%)Outcome Measures for Medical/Interventional and Surgical Treatment, n (%)1/1 (100%)1/1 (100%)Medical and Interventional Treatment, n (%)0/7 (0%)0/7 (0%)Surgical Treatment, n (%)3/8 (38%)3/8 (38%)Value of Spine Care, n (%)0/3 (0%)0/3 (0%)
On the other hand, ChatGPT 4.0 answered 13 (42%) of the 31 total questions in concordance with NASS guidelines. ChatGPT 4.0 answered 100% concordantly on “Definitions and Natural History” (2/2). It also performed well on “Diagnosis and Imaging” with an 80% concordance rate (4/5) and “Outcome Measures for Medical/Interventional and Surgical Treatment” with 100% concordance rate. However, it did not answer any questions concordantly in “Medical and Interventional Treatment” (0/7, 0%). In the category of “Surgical Treatment,” it had a concordance rate of 46.1% (6/13). For “Value of Spine Care” questions, it again had a 0% concordance rate (0/3).
When answering questions for which NASS offered a definitive recommendation, ChatGPT 4.0 performed slightly worse than ChatGPT 3.5, achieving a concordance rate of 82% (9/11) (Table 2). For questions where NASS refrained from providing a direct recommendation, ChatGPT 4.0 performed the same as ChatGPT 3.5, with a concordance rate of 20% (4/20) (Table 3).
Our analysis reveals notable differences between the recommendations generated by ChatGPT and the official NASS clinical guidelines regarding adult isthmic spondylolisthesis.1.General Concordance: Both ChatGPT versions showed similar overall concordance with NASS recommendations, with ChatGPT 3.5 slightly outperforming ChatGPT 4.0 (45% vs. 42%).2.Category-Specific Performance: Differences were particularly evident in the categories of “Medical and Interventional Treatment” (0% concordance for both versions), “Value of Spine Care” (0% concordance for both versions), and “Surgical Treatment” (54% and 46% concordance for ChatGPT 3.5 and 4.0, respectively).3.Clear vs. Ambiguous Guidelines: Both models performed significantly better when NASS provided clear recommendations (82% and 91% concordance) compared to questions where NASS noted a lack of evidence (20% concordance for both versions).
NASS and ChatGPT 3.5 and 4.0 provided similar answers on the definition and natural history of adult isthmic spondylolisthesis. Similar results were seen in the study that examined the differences between ChatGPT and NASS clinical guidelines for degenerative spondylolisthesis. In this study, 100% of the answers were also seen as concordant between the two groups regarding definition and natural history [11]. Probably due to the lack of specific medical language, which may be seen as a barrier for ChatGPT, these kinds of questions were easier compared to those regarding treatment.
For the Diagnosis and Imaging sections of the questions, NASS provides comprehensive recommendations regarding symptoms, clinical presentation, and the frequency of abnormal findings. However, for questions concerning diagnostic tools and physical examination, NASS offers only partial recommendations. Regarding the relationship between the radiological grade of isthmic spondylolisthesis and the expected clinical presentation, NASS states that no available literature can adequately answer this question, and therefore, they do not provide any recommendations for this aspect. The responses from ChatGPT 3.5 and 4.0 are consistent with those provided by NASS. However, for the question where NASS indicated a lack of available literature, ChatGPT attempts to provide related information. While neither directly answers the question, they offer some findings that might give clues about the potential answer. Especially ChatGPT 4.0, which provides a summary such “The relationship between the radiological grade and the clinical presentation is important but not always straightforward, as the severity of symptoms does not always correlate directly with the degree of slippage.” This sentence can be supported by literature that examines similar concepts and whose findings align with the statement provided by ChatGPT 4.0 [12], [13], [14].
For questions regarding outcome measures for medical, interventional, and surgical treatments, the North American Spine Society (NASS) guidelines recommend obtaining a copy of the ``Compendium of Outcome Instruments for Assessment and Research of Spinal Disorders.'' This Compendium, published in 2006, bases the NASS recommendations on the literature available at that time [15]. Both ChatGPT versions 3.5 and 4.0 emphasize the importance of incorporating both objective and subjective measures for a comprehensive assessment. Additionally, ChatGPT provides examples of instruments that can be used for this purpose, such as the Visual Analog Scale (VAS) and the Numeric Rating Scale (NRS). These recommendations align with those from NASS, which also highlight the importance of comprehensive approaches.
Questions regarding medical and interventional treatment from NASS (North American Spine Society) are related to the available options for treatment, such as pharmacological treatment, manipulation, steroid injections, ancillary treatments, and physical therapy (5 questions), as well as factors influencing outcomes and long-term results (2 questions). NASS stated that there is no available evidence to address clinical questions for 5 questions. Both ChatGPT instances failed to answer any questions in this group.
On the questions regarding pharmacological treatment, steroid injections and ancillary treatments, ChatGPT instances concluded that this type of treatment plays a supportive role, primarily for symptom relief. The literature indicates that NSAIDs, steroid injections and ancillary treatments are one of the conservative options for treating isthmic spondylolisthesis [16,17]. That may explain the answer provided by ChatGPT. However, on the question regarding physical therapy, ChatGPT stated that it plays a critical role in the management of isthmic spondylolisthesis. Firstly, this is not consistent with the NASS guidelines, which state that there is insufficient evidence for or against the use of physical therapy. Secondly, the literature also does not provide consistent recommendations regarding this treatment option. For example, Burton (2024) stated that physical therapy is a type of conservative option rather than a central one [16]. The systematic review comparing treatment options for adult spondylolisthesis stated that those options, which also include physical therapy, still yields worse outcomes compared to surgical treatment [18]. Therefore, the assertion made by ChatGPT regarding the critical role of physical therapy may not align with the current consensus in the field.
On the contrary, when ChatGPT recommended physical therapy, steroid injections, pharmacological treatment, and ancillary treatments, it advised against the use of manipulation, a stance which NASS still deems due to a lack of evidence. Manipulation is not often endorsed in the literature as one of the treatment options. A study from 1978 indicated that there is no contraindication to using manipulative therapy while treating spondylolisthesis [19]. However, a study from 2004 recommended that this type of treatment should be used cautiously, primarily targeting the joints above and below the spondylolisthesis [20]. Nevertheless, the results of the 1978 study are debatable due to its age, and the 2004 study is a single case study, which may not be sufficient to establish a general recommendation. This strongly suggests that ChatGPT's recommendation lacks support in the evidence-based literature.
For the question regarding factors influencing the outcomes of patients treated with medical or interventional treatment, the North American Spine Society (NASS) noted a lack of specific recommendations. ChatGPT 3.5 suggested that radiological factors might influence these treatments but also highlighted the limited evidence available. In contrast, ChatGPT 4.0 clearly stated that factors such as the degree of radiological grade, sagittal spinopelvic alignment, sacral and spinopelvic parameters, and the presence of dynamic instability in patients with isthmic spondylolisthesis significantly affect the outcomes.
Regarding the question about long-term results, the responses from ChatGPT did not directly address the query as posed. While the NASS inquired about specific long-term results, both versions of ChatGPT emphasized that these results depend on various factors. ChatGPT 3.5 highlighted aspects such as functional improvement, prevention of progression, complication rates, and patient satisfaction. These factors are consistent with findings from researchers who have studied the long-term outcomes of spondylolisthesis treatments [21,22]. Moreover, Weinstein et al. (2007) in their study highlighted the importance of stabilization of slippage, improvement in quality of life, and variability in individual outcomes, which were among the factors suggested by ChatGPT 4.0.
The group of questions regarding surgical treatment was the largest among all, comprising 13 questions. These can be categorized into a few categories such as comparative effectiveness of surgical vs. medical/interventional treatment (1 question), comparative effectiveness of different surgical approaches (7 questions), factors affecting surgical outcomes (2 questions), and long-term and prognostic considerations (3 questions). ChatGPT 3.5 answered consistently on 7 of them, which accounts for 54% of the total questions in this category. Meanwhile, ChatGPT 4.0 performed slightly worse by answering 6 questions consistently (46%). NASS indicated a lack of evidence on 5 of them (38%) and insufficient evidence on 3 of them (23%), which combined can be seen as NASS being able to answer 5 questions (31%) of the questions in this category based on evidence-based literature.
For the first question, which is a general inquiry about the comparative effectiveness of surgical versus medical/interventional treatment, both ChatGPTs answered consistently with NASS's recommendation, stating that there is no single general recommendation on which treatment is more effective as all of them have advantages and disadvantages that should be taken into account. The literature supports the view that even if one treatment option may show some dominance over the other in specific scenarios, healthcare providers should still consider both surgical and nonsurgical options when dealing with patients with isthmic spondylolisthesis. This approach ensures that treatment is individualized based on the patient's unique circumstances and needs [23], [24], [25].
In addressing the comparative efficacy of different surgical approaches for isthmic spondylolisthesis, there were notable differences between ChatGPT 3.5 and ChatGPT 4.0 and their alignment with the North American Spine Society (NASS) recommendations. Specifically, when evaluating whether the addition of instrumentation to decompression and fusion improves surgical outcomes compared with decompression and fusion alone, ChatGPT 3.5 was concordant with NASS recommendations, suggesting dependency of various factors. Similar result were seen in the study specifically addresses surgical outcomes in adult patients with isthmic spondylolisthesis, comparing different surgical techniques, including the use of instrumentation [23]. ChatGPT 4.0 did not align with this recommendation, indicating that adding instrumentation shows benefits over decompression. Conversely, on the question regarding the role of stand-alone interbody fusion for indirect decompression in the treatment of adult patients with isthmic spondylolisthesis, ChatGPT 3.5′s response was nonconcordant with NASS recommendations, whereas ChatGPT 4.0 demonstrated concordance, supporting the utility of this surgical approach in similar pattern as NASS recommendation.
Differences between the answers provided by both versions of ChatGPT were also observed in the question regarding the long-term results (four+ years) of surgical management of adult patients with isthmic spondylolisthesis. ChatGPT 3.5 aligned with the NASS recommendations by stating that many different aspects should be considered when evaluating long-term outcomes, and it cannot provide a single, definitive answer regarding the results (NASS, 2014). This reflects the complexity and variability of outcomes based on individual patient factors such as age, overall health, degree of spondylolisthesis, and surgical technique used.
However, ChatGPT 4.0 provided a more specific answer, stating that generally the long-term results of surgical management are positive in many different aspects. This response fails to capture the nuanced understanding required, as highlighted by NASS, that long-term outcomes can vary significantly based on patient-specific variables and that a blanket statement about positive results may not apply to all patients. The differences may also be explained by the fact that ChatGPT 3.5 and ChatGPT 4.0 are iterations of the GPT model developed by OpenAI, with each version trained on different datasets and possibly updated guidelines and literature. ChatGPT 4.0 could have been optimized to provide more focused or specialized responses in certain areas of inquiry, which may make its responses appear more specific compared to earlier versions [26]. However, as shown in our study results, its accuracy still needs to be improved to provide evidence-based knowledge.
The North American Spine Society (NASS) identified three key questions regarding the value of spine care that remain inadequately addressed due to a lack of evidence. Additionally, there are discrepancies between NASS recommendations and the responses provided by ChatGPT 3.5 and ChatGPT 4.0 for all three questions.
The first and second question concerns the cost-effectiveness of medical or interventional treatment methods. Both versions of ChatGPT indicated that the most cost-effective treatment approach depends on various individual patient factors and the availability of healthcare resources. Numerous studies suggest that personalized approaches are necessary to determine the optimal treatment modality for lumbar degenerative spondylolisthesis, taking into account healthcare resource considerations [27], [28], [29].
Furthermore, ChatGPT 4.0 noted a general consensus that conservative treatment approaches tend to be more cost-effective for mild to moderate cases of isthmic spondylolisthesis. This aligns with the literature that highlights the benefits and cost savings associated with nonsurgical treatments for such conditions [30,31].
The third inquiry, concerning the selection of the most cost-effective surgical treatment, reveals disparities between the responses from both ChatGPT models and the NASS guidelines. Both iterations of ChatGPT consistently emphasize the importance of individual patient factors and advocate for shared decision-making in treatment planning (Table 4). Additionally, ChatGPT 4.0 posits that there is sufficient evidence to recommend decompression with fusion as a cost-effective treatment option. This recommendation is supported by studies suggesting that decompression with fusion can be cost-effective depending on the specific circumstances of the patient [24,32], thereby explaining ChatGPT 4.0′s inclination towards this treatment modality.Table 4NASS guideline questions with its recommendations, a summary of ChatGPT responses, and our evaluation along with the rationale.Table 4Clinical QuestionsAnswer from NASS's Evidence-based Clinical Guidelines for Multidisciplinary Spine Care—Diagnosis and Treatment of Adult Isthmus SpondylolisthesisChat GPT 3.5 Response—summaryGrading and RationaleChat GPT 4.0 Response—summaryGrading and RationaleDefinition and Natural HistoryWhat is the best working definition of isthmic spondylolisthesis?Isthmic spondylolisthesis is the anterior translation of one lumbar vertebra relative to the next caudal segment as a result of an abnormality in the pars interarticularis. When symptomatic, this causes a variable clinical syndrome of back and/or lower extremity pain, and may include varying degrees of neurologic deficits at or below the level of the injury.Work Group Consensus StatementIsthmic spondylolisthesis is a condition where one vertebra slips forward over the vertebra below it due to a defect in the pars interarticularis, which is a small bony segment joining the facet joints in the back of the spine.Grade: ConcordantRationale: Chat GPT accurately and concisely described definition of isthmic spondylolisthesis.Isthmic spondylolisthesis is a condition characterized by the anterior displacement of a vertebra in relation to the one beneath it, caused by a defect or fracture in the pars interarticularis. This defect can compromise spinal stability and alignment, leading to pain, limited mobility, and in some cases, neurological symptoms.Grade: ConcordantRationale: Both statements describe isthmic spondylolisthesis, a condition where one vertebra slips forward in relation to the one below it due to an abnormality in the pars interarticularis. Both descriptions mention the potential symptoms such as back and/or lower extremity pain and neurological deficits resulting from this displacement. They also emphasize the importance of spinal stability and alignment in relation to this condition. Overall, they are concordant in their portrayal of isthmic spondylolisthesis.What is the likelihood that spondylolysis (unilateral and/or bilateral, identified in adolescence or adulthood) will progress to become a symptomatic spondylolisthesis?Spondylolisthesis occurs in 40% to 66% of patients with bilateral spondylolysis. Spondylolisthesis is unlikely to occur in patients with unilateral spondylolysis.Grade of Recommendation: BThe likelihood of spondylolysis progressing to symptomatic spondylolisthesis can vary depending on several factors, including the severity of the initial defect, individual anatomy, activity level, and management of the condition.Grade: ConcordantRationale: Chat GPT 3.5 concisely described the risk factors of spondylolysis will progress to become a symptomatic spondylolisthesisThe likelihood that spondylolysis will progress to symptomatic spondylolisthesis varies and depends on several factors, including the age at diagnosis, the extent of the defect (whether it is unilateral or bilateral), activity level, and specific biomechanical forces on the spine.Grade: ConcordantRationale: Even if Chat GPT 4.0 gave a bit more details then chat GPT 3.5 to described the risk factors of spondylolysis will progress to become a symptomatic spondylolisthesis(the meaning is still the same)Diagnosis and ImagingWhat are the most appropriate physical examination findings consistent with the diagnosis of isthmic spondylolisthesis in adult patients?•There is insufficient evidence to make a recommendation for or against the use of palpation in the physical exam diagnosis of adult patients with isthmic spondylolisthesis.Grade of Recommendation: I (Insufficient Evidence)•Approximately half of adult patients with symptomatic isthmic spondylolisthesis will have a positive straight leg test on examination.Grade of Recommendation: BIn adult patients with isthmic spondylolisthesis, several physical examination findings may be consistent with the diagnosis. These findings can vary depending on the severity of the spondylolisthesis and any associated nerve compression or spinal instability. Some of the most appropriate physical examination findings consistent with isthmic spondylolisthesis in adult patients may Reduced lumbar range of Limited movement in the lumbar spine, especially extension and rotation, may be observed due to instability or pain associated with the spondylolisthesis.Lumbar paraspinal muscle Tenderness and tightness in the muscles along the lower back, particularly on the affected side, can be present due to the body's attempt to stabilize the spine.Positive straight leg raise This test involves lifting the leg while the patient is lying on their back to assess for signs of nerve root irritation or compression, which can occur with isthmic spondylolisthesis.Neurological Depending on the degree of slippage and compression of the spinal nerves, patients may exhibit neurological symptoms such as weakness, numbness, or tingling in the lower extremities. Reflexes may also be diminished or absent.Positive step-off A visible step-off or prominence of one vertebra over another may be palpable along the spine, particularly in the lower lumbar region, indicating the presence of spondylolisthesis.Positive pelvic compression This test involves applying downward pressure on the pelvis to reproduce symptoms associated with spondylolisthesis, such as pain or discomfort in the lower back or legs.Grade: ConcordantRationale: Both statements emphasize the complexity of diagnosing isthmic spondylolisthesis and suggest that a combination of physical examination findings may be more useful than any single test or observation alone. But Chet GPT 3.5 gave more details.Here are some key physical examination findings that are considered appropriate when assessing for isthmic Palpation: Tenderness at the site of the defect (pars interarticularis), which is located in the lower lumbar region. Patients might also present with palpable step-off at the level of the affected vertebra if there is significant slippage.Postural Changes: Observation of postural abnormalities such as increased lumbar lordosis or a more flattened lumbar curve depending on the compensation mechanisms. A visible step in the lower back or an abnormal silhouette of the spine might be seen.Range of Motion: Limited lumbar range of motion, especially in extension, because extending the spine may increase pain or discomfort by further displacing the affected vertebrae.Neurological Examination:Straight Leg Raise Test: This test can elicit symptoms of sciatic nerve irritation, suggesting nerve root impingement due to vertebral displacement.Motor Strength, Reflexes, and Sensation: Assessment of lower extremity motor strength, reflexes, and sensory function can help determine if there is any nerve root compression. Decreased reflexes, muscle weakness, and sensory deficits might be present depending on the nerve roots affected.Gait Assessment: Changes in gait pattern, such as a cautious gait or alterations in stride length and speed, might indicate compensation for pain or instability in the lumbar region.Pain Provocation Tests:Extension Test: Pain during back extension can indicate spondylolisthesis, as it stresses the pars interarticularis.Single-Leg Hyperextension Test (Stork Test): Performing this test may reproduce pain and is used to identify lumbar spine instability. The patient stands and lifts one foot off the ground while extending the spine; reproduction of pain on the ipsilateral side suggests the presence of spondylolysis or spondylolisthesis.Grade: ConcordantRationale: Both sets emphasize the importance of multiple physical examination findings and tests in diagnosing isthmic spondylolisthesis and indicate that no single test, including palpation, is sufficient on its own for diagnosis. Chet GPT 4.0 elaborates on various physical examination findings consistent with isthmic spondylolisthesis, including palpation, postural changes, range of motion limitations, neurological examination (including the straight leg raise test), motor strength, reflexes, sensation, gait assessment, and pain provocation tests.In adult patients, what symptoms or clinical presentation are associated with the diagnosis of isthmic spondylolisthesis?In adult patients with symptomatic isthmic spondylolisthesis, most patients present with low back pain and at least half present radicular lower extremity pain.Grade of Recommendation: BIn adult patients, isthmic spondylolisthesis can present with a variety of symptoms and clinical manifestations, which may Lower back This is one of the most common symptoms associated with isthmic spondylolisthesis. The pain may be localized to the lower back or may radiate into the buttocks or thighs.Intermittent or chronic leg Pain may radiate into one or both legs, typically following the path of the affected nerve roots. This pain may be sharp, shooting, or burning in nature.Pain with Symptoms may worsen with certain activities such as standing, walking, or prolonged sitting, and may improve with rest.Stiffness and limited range of Patients may experience stiffness and reduced flexibility in the lower back, especially with bending, twisting, or extending the spine.Neurological Depending on the degree of spinal nerve compression, patients may experience neurological symptoms such as numbness, tingling, or weakness in the legs. In severe cases, bladder or bowel dysfunction may occur, indicating cauda equina syndrome.Pain with certain Symptoms may be exacerbated by certain movements, such as hyperextension of the spine or activities that involve repetitive bending and lifting.Visible In some cases of advanced spondylolisthesis, a visible deformity or abnormal curvature of the spine (kyphosis or lordosis) may be apparent.Instability: Patients may describe a feeling of instability or ``giving way'' in the lower back, especially during physical activity.Grade: ConcordantRationale: Both highlight that lower back pain is a common symptom of isthmic spondylolisthesis, often accompanied by leg pain that may radiate, worsen with activity, and improve with rest. Additionally, they mention neurological symptoms, such as numbness and weakness, and the potential for bladder or bowel dysfunction in severe cases. ChatGPT 3.5 gave more details.Here are some common symptoms and aspects of the clinical Low Back Pain: This is the most common symptom. The pain can be chronic and dull or sharp and severe, and it may be exacerbated by activities that involve lumbar extension or heavy physical exertion.Leg Pain (Sciatica): Compression or irritation of the nerve roots often leads to radiating pain down the buttocks and legs, commonly known as sciatica. This symptom can be exacerbated by standing or walking and may improve with lying down.Neurogenic Claudication: In cases where the spinal canal is narrowed (spinal stenosis) due to the vertebral slippage, patients may experience pain, numbness, and weakness in the legs that worsens with walking and improves with rest or lumbar flexion (e.g., sitting or bending forward).Numbness or Tingling: These sensations typically occur in the lower extremities and are due to nerve compression.Muscle Weakness: Weakness in the legs can occur, particularly in the distribution of the affected nerve roots. This might affect the patient's gait and ability to perform certain activities.Tight Hamstring Muscles: Patients often experience increased tightness in the hamstring muscles, which can affect their range of motion and posture.Postural Changes: Increased lumbar lordosis, a visible step-off at the back, or changes in the way the patient stands or walks might be noted due to the attempt to reduce pain or compensate for instability in the spine.Changes in Bowel or Bladder Function: Although less common, severe cases of nerve compression can lead to cauda equina syndrome, a medical emergency characterized by severe lower back pain, loss of bowel or bladder control, and significant leg weakness.Reduced Mobility: Due to pain and mechanical instability, some patients may exhibit a reduced range of spinal motion, particularly in lumbar extension.Grade: ConcordantRationale: The same like ChatGPT.What are the most appropriate diagnostic tests for adult isthmic spondylolisthesis?•There is a relative paucity of high quality studies on imaging in adult patients with isthmic spondylolisthesis. It is the opinion of the work group that in adult patients with history and physical examination findings consistent with isthmic spondylolisthesis, standing plain radiographs, with or without oblique views or dynamic radiographs, be considered as the most appropriate, noninvasive test to confirm the presence of isthmic spondylolisthesis. In the absence of a reliable diagnosis on plain radiographs, CT scan is considered the most reliable diagnostic test to diagnose a defect of the pars interarticularis. In adult patients with radiculopathy, MRI should be considered.Work Group Consensus Statement•MRI is suggested to identify neuroforaminal stenosis in adult patients with isthmic spondylolisthesis.Grade of Recommendation: B•There is insufficient evidence to make a recommendation for or against the use of MRI to differentiate isthmic versus degenerative spondylolisthesis in adult patients.Grade of Recommendation: I (Insufficient Evidence)•There is insufficient evidence to make a recommendation for or against the use of discography to evaluate adult patients with isthmic spondylolisthesis.Grade of Recommendation: I (Insufficient Evidence)•CT may be considered as an option to diagnose isthmic spondylolisthesis in adult patients.Grade of Recommendation: C•There is insufficient evidence to make a recommendation for or against the use of SPECT in evaluating isthmic spondylolisthesis in adult patients.Grade of Recommendation: I (Insufficient Evidence)The diagnosis of isthmic spondylolisthesis in adults typically involves a combination of clinical evaluation and diagnostic imaging studies. The most appropriate diagnostic tests for adult isthmic spondylolisthesis X-rays: X-rays of the lumbar spine are often the initial imaging modality used to evaluate for isthmic spondylolisthesis. X-rays can provide detailed images of the spine in multiple planes, allowing visualization of vertebral alignment, slippage (spondylolisthesis), and any associated bony abnormalities such as pars interarticularis defects (spondylolysis).MRI (Magnetic Resonance Imaging): MRI is a highly sensitive imaging modality that can provide detailed images of the soft tissues, including the spinal cord, nerve roots, intervertebral discs, and surrounding structures. MRI is useful for evaluating spinal nerve compression, disc herniation, and any signs of spinal stenosis or other pathology that may be contributing to symptoms.CT (Computed Tomography) Scan: CT scans can provide detailed images of the bony structures of the spine, including the pars interarticularis, facet joints, and vertebral bodies. CT scans are particularly useful for assessing bony abnormalities such as spondylolysis and evaluating the degree of slippage (spondylolisthesis).Dynamic X-rays: Dynamic X-rays, also known as flexion-extension X-rays, involve obtaining X-ray images of the lumbar spine while the patient is in different positions, such as bending forward (flexion) and backward (extension). Dynamic X-rays can help assess for spinal instability and the degree of movement between vertebrae, which is important in evaluating isthmic spondylolisthesis.Bone Scan: In some cases, a bone scan may be used to detect increased bone turnover and identify areas of active bone remodelling, which can be indicative of spondylolysis or other spinal pathology.Electromyography (EMG) and Nerve Conduction Studies: EMG and nerve conduction studies may be performed to assess nerve function and identify any nerve root compression or dysfunction associated with isthmic spondylolisthesis.Grade: ConcordantRationale: The provided information and consensus statement are generally aligned regarding the diagnostic approach to isthmic spondylolisthesis in adultsHere are the most appropriate diagnostic tests for this X-rays: Standing lateral and AP X-rays are the primary imaging modality used to diagnose isthmic spondylolisthesis. They can clearly show the anterior displacement of the vertebra relative to the one below it. Lateral views are particularly useful for assessing the degree of slippage (graded I through V based on the amount of displacement).Flexion-extension X-rays: These are useful to assess the stability of the spine and to see if there is any change in the degree of vertebral slippage with movement.Magnetic Resonance Imaging (MRI):An MRI is excellent for assessing soft tissue structures including discs, ligaments, and especially the nerves and spinal cord. It helps in evaluating associated conditions such as disc herniation or spinal stenosis, and it provides detailed images of nerve roots, which is crucial for diagnosing the cause of neurological symptoms.Computed Tomography (CT) Scan:A CT scan provides detailed images of the bone structures of the spine and is particularly useful in evaluating the bony anatomy and integrity of the pars interarticularis. It can detect small fractures or defects in the bone that might not be visible on an X-ray.CT Myelogram:In cases where MRI is contraindicated or if further detail is needed regarding nerve root compression, a CT myelogram can be performed. This involves injecting a contrast dye into the spinal canal before taking a CT scan, providing detailed images of the spinal canal and nerve roots.Bone Scan:Although less commonly used for isthmic spondylolisthesis, a bone scan can help identify areas of increased stress or activity in the bone, such as a fracture in the pars interarticularis, especially in cases where the diagnosis is uncertain.Electromyography (EMG) and Nerve Conduction Studies (NCS):These tests are not routinely used in the diagnosis of isthmic spondylolisthesis but can be helpful in assessing the extent of nerve damage and differentiating leg pain caused by nerve compression from other causes like peripheral neuropathy or muscle injury.Grade: ConcordantRationale:ChatGPT4.0 offers a broader overview of diagnostic modalities including X-rays, MRI, CT scans, CT myelogram, bone scans, and electromyography, highlighting their respective roles in evaluating different aspects of the condition.In adult patients, what is the relationship between the radiological grade of isthmic spondylolisthesis and expected clinical presentation?A systematic review of the literature yielded no studies to adequately address this question.The radiological grade of isthmic spondylolisthesis, as determined by imaging studies such as X-rays or MRI scans, can provide important information about the severity of the condition and its potential impact on clinical presentation in adult patients. Generally, the severity of spondylolisthesis is graded based on the percentage of slippage of one vertebra over the adjacent vertebra, with Grade I representing 0%-25% slippage, Grade II representing 25%-50% slippage, Grade III representing 50%-75% slippage, and Grade IV representing 75%-100% slippage.Grade: NonconcordantRationale:The two statements are not directly related. NASS's Evidence indicates that a systematic review of the literature did not find any studies that adequately addressed a particular question. This suggests a gap in the existing research.Chat GPT3.5 provides information about how the severity of isthmic spondylolisthesis is typically assessed using radiological grading based on the percentage of slippage of one vertebra over another. It does not address whether there are studies addressing a specific question related to isthmic spondylolisthesis.The radiological grade of isthmic spondylolisthesis in adults is typically assessed using the Meyerding grading system, which divides the slippage of the vertebral body into five grades based on the percentage of displacement over the vertebra below. The relationship between the radiological grade and the clinical presentation is important but not always straightforward, as the severity of symptoms does not always correlate directly with the degree of slippage.Grade: NonconcordantRationale: The two statements are not directly related. NASS's Evidence indicates that a systematic review of the literature did not find any studies that adequately addressed a particular question. This suggests a gap in the existing research.Chat GPT4.0 provides information about how the radiological grade of isthmic spondylolisthesis is typically assessed using the Meyerding grading system and highlights the complexity of the relationship between radiological grade and clinical presentation. It discusses how the severity of symptoms may not always directly correlate with the degree of slippage.How frequently do adult patients with isthmic spondylolisthesis have abnormal findings of their sagittal spinopelvic alignment, sacral alignment and spinopelvic parameters?Adult patients with a diagnosis of isthmic spondylolisthesis have a higher pelvic incidence, sacral slope, pelvic tilt and lumbar lordosis compared to patients without isthmic spondylolisthesis.Grade of Recommendation: BOverall, while abnormalities in sagittal spinopelvic alignment, sacral alignment, and spinopelvic parameters are relatively common in adult patients with isthmic spondylolisthesis, the exact prevalence may vary among individuals and populations. These abnormalities may contribute to the development, progression, and symptomatic manifestations of isthmic spondylolisthesis and should be carefully evaluated and managed as part of the overall treatment approachGrade: ConcordantRationale: both NASS's Evidence and ChatGPT3.5 highlight the importance of understanding and managing abnormalities in sagittal spinopelvic alignment in the context of isthmic spondylolisthesis in adult patients.In summary, abnormalities in sagittal spinopelvic alignment and related parameters are frequently observed in adults with isthmic spondylolisthesis, reflecting the body's attempt to maintain an upright posture and balance despite the structural changes in the spine.Grade: ConcordantRationale: both NASS's Evidence and ChatGPT4.0 contribute to the understanding that abnormalities in sagittal spinopelvic alignment are common in adults with isthmic spondylolisthesis, although the first statement highlights a lack of specific studies addressing a particular question, while the second statement summarizes the general observation of such abnormalities.Outcome Measures for Medical/Interventional and Surgical TreatmentWhat are the appropriate outcome measures for the treatment of adult isthmic spondylolisthesis?For information on outcome measures for spinal disorders, the North American Spine Society has a publication entitled Compendium of Outcome Instruments for Assessment and Research of Spinal Disorders. To purchase a copy of the Compendium, visit https://webportal.spine.org/ Purchase/ProductDetail.aspx?Product_code=68cdd1f4-c4ac-db11-95b2-001143edb1c1. For additional information about the Compendium, please contact the NASS Research Department at nassresearch@spine.org.The appropriate outcome measures for the treatment of adult isthmic spondylolisthesis should encompass a comprehensive assessment of various domains, including pain relief, functional improvement, quality of life, patient satisfaction, and complication rates.Grade: ConcordantRationale: both NASS's Evidence and ChatGPT3.5 suggest that the Compendium mentioned in the first statement might be a valuable resource for clinicians and researchers seeking to select appropriate outcome measures for evaluating the treatment outcomes of adult isthmic spondylolisthesis, as it likely contains instruments relevant to the domains mentioned in the second statement.When evaluating the outcomes of treatment for adult isthmic spondylolisthesis, both subjective and objective measures are used to assess the effectiveness of the intervention, whether surgical or nonsurgical.Grade: ConcordantRationale: both NASS's Evidence and ChatGPT4.0 suggest that the Compendium could be a valuable resource for clinicians and researchers evaluating treatment outcomes for adult isthmic spondylolisthesis, as it likely contains measures that encompass both subjective and objective aspects of assessment.Medical and Interventional TreatmentWhat is the role of pharmacological treatment in the management of isthmic spondylolisthesis?There was no evidence to address this clinical question. Due to the paucity of literature addressing this question, the work group was unable to generate a recommendation.Pharmacological treatment plays a supportive role in the management of isthmic spondylolisthesis, primarily aimed at providing symptomatic relief from pain and inflammation.Grade: NonconcordantRationale: For NASS's Evidence, Due to insufficient evidence, the work group couldn't generate a recommendation for this clinical question. But for ChatGPT3.5, Pharmacological treatment plays a supportive role in the management of isthmic spondylolisthesis.Pharmacological treatment plays a supportive role in the management of isthmic spondylolisthesis, primarily aimed at managing symptoms such as pain and inflammation, rather than addressing the underlying structural issues of the spine.Grade: NonconcordantRationale: For NASS's Evidence, Due to insufficient evidence, the work group couldn't generate a recommendation for this clinical question. But for ChatGPT4.0, Pharmacological treatment plays a supportive role in the management of isthmic spondylolisthesis.What is the role of manipulation in the treatment of isthmic spondylolisthesis?There was no evidence to address this clinical question. Due to the paucity of literature addressing this question, the work group was unable to generate a recommendation.The role of manipulation, specifically spinal manipulation performed by chiropractors or osteopathic physicians, in the treatment of isthmic spondylolisthesis is controversial and generally not recommended as a primary treatment modality.Grade: NonconcordantRationale: For NASS's Evidence, Due to insufficient evidence, the work group couldn't generate a recommendation for this clinical question. But for ChatGPT3.5,Spinal manipulation by chiropractors or osteopathic physicians for isthmic spondylolisthesis is controversial and not typically recommended as a primary treatment.The role of spinal manipulation in the treatment of isthmic spondylolisthesis is quite cautious and limited, primarily due to the potential risk of exacerbating the existing vertebral slippage.Grade: NonconcordantRationale: For NASS's Evidence, Due to insufficient evidence, the work group couldn't generate a recommendation for this clinical question. But for ChatGPT4.0, Spinal manipulation's role in treating isthmic spondylolisthesis is limited due to the risk of worsening vertebral slippage.What is the role of steroid injections for the treatment of isthmic spondylolisthesis?There was no evidence to address this clinical question. Due to the paucity of literature addressing this question, the work group was unable to generate a recommendation.Steroid injections, specifically epidural steroid injections (ESIs), may be used in the management of isthmic spondylolisthesis to provide temporary relief from pain and inflammation associated with nerve root compression or irritation.Grade: NonconcordantRationale: For NASS's Evidence, Due to insufficient evidence, the work group couldn't generate a recommendation for this clinical question. But for ChatGPT3.5,ESIs may temporarily relieve pain and inflammation in isthmic spondylolisthesis.Steroid injections, particularly epidural steroid injections (ESIs), play a specific role in the management of pain associated with isthmic spondylolisthesis, especially when conservative measures such as oral medications and physical therapy are not sufficient. The main goal of these injections is to reduce inflammation and alleviate pain, particularly when nerve root irritation or compression is involved.Grade: NonconcordantRationale: For NASS's Evidence, Due to insufficient evidence, the work group couldn't generate a recommendation for this clinical question. But for ChatGPT4.0, ESIs are key in managing isthmic spondylolisthesis pain when conservative methods fall short, aiming to reduce inflammation and ease nerve-related discomfort.What is the role of ancillary treatments such as bracing, traction, electrical stimulation and transcutaneous electrical stimulation (TENS) in the treatment of isthmic spondylolisthesis?There was no evidence to address this clinical question. Due to the paucity of literature addressing this question, the work group was unable to generate a recommendation.Ancillary treatments such as bracing, traction, electrical stimulation, and transcutaneous electrical nerve stimulation (TENS) may be considered as adjunctive therapies in the management of isthmic spondylolisthesis, particularly for patients who experience persistent symptoms despite conservative measures. These ancillary treatments are typically used to alleviate pain, improve spinal stability, and enhance functional outcomes.Grade: NonconcordantRationale: For NASS's Evidence, Due to insufficient evidence, the work group couldn't generate a recommendation for this clinical question. But for ChatGPT3.5,Ancillary treatments like bracing, traction, and TENS can aid in managing isthmic spondylolisthesis symptoms.Ancillary treatments such as bracing, traction, electrical stimulation, and Transcutaneous Electrical Nerve Stimulation (TENS) can play supportive roles in the comprehensive management of isthmic spondylolisthesis, particularly as adjuncts to primary treatments like physical therapy, medication, and potentially surgery.Grade: NonconcordantRationale: For NASS's Evidence, Due to insufficient evidence, the work group couldn't generate a recommendation for this clinical question. But for ChatGPT4.0, Ancillary treatments like bracing, traction, and TENS support managing isthmic spondylolisthesis alongside primary therapies such as physical therapy and medication.What is the role of physical therapy/exercise in the treatment of isthmic spondylolisthesis?There is insufficient evidence to make a recommendation for or against the use of physical therapy/ exercise for the treatment of isthmic spondylolisthesis.Grade of Recommendation: I (Insufficient Evidence)Physical therapy and exercise play a critical role in the management of isthmic spondylolisthesis by addressing pain, improving spinal stability, enhancing mobility, and optimizing overall function and quality of life.Grade: NonconcordantRationale: While the NASS's Evidence suggests uncertainty due to insufficient evidence, ChatGPT3.5 asserts the significance of physical therapy and exercise in the management of isthmic spondylolisthesis.Physical therapy and exercise play a central role in the management of isthmic spondylolisthesis, focusing on improving spinal stability, reducing pain, and enhancing overall physical function.Grade: NonconcordantRationale: While the NASS's Evidence suggests uncertainty due to insufficient evidence, ChatGPT4.0 emphasizes the significant role of physical therapy and exercise in the management of isthmic spondylolisthesis.Does the degree of radiological grade, sagittal spinopelvic alignment, sacral and spinopelvic parameters, or the presence of dynamic instability in patients with isthmic spondylolisthesis affect the outcomes of patients treated with medical or interventional treatment?There was no evidence to address this clinical question. Due to the paucity of literature addressing this question, the work group was unable to generate a recommendation.The relationship between radiological grade, sagittal spinopelvic alignment, sacral and spinopelvic parameters, presence of dynamic instability, and treatment outcomes in patients with isthmic spondylolisthesis is an area of active research and clinical interest. While there is some evidence to suggest that these radiological factors may influence treatment outcomes, the specific impact varies depending on individual patient characteristics, severity of spondylolisthesis, and the type of treatment provided.Grade: NonconcordantRationale: NASS's Evidence asserts a lack of evidence and an inability to make any recommendations.ChatGPT 3.5 statement acknowledges existing evidence and indicates variability in how radiological factors might influence treatment outcomes, suggesting that recommendations could be made under specific contexts.Yes, the degree of radiological grade, sagittal spinopelvic alignment, sacral and spinopelvic parameters, and the presence of dynamic instability in patients with isthmic spondylolisthesis significantly affect the outcomes of those treated with medical or interventional treatments.Grade: NonconcordantRationale: NASS's Evidence indicates no evidence and an inability to generate recommendations.ChatGPT3.5 indicates strong evidence supporting a significant impact of the radiological factors on treatment outcomes.What is the long-term result of medical/interventional management of isthmic spondylolisthesis?There is insufficient evidence to make a recommendation for or against the use of medical/ interventional treatment for the long-term management of patients with isthmic spondylolisthesis.Grade of Recommendation:I (Insufficient Evidence)The long-term results of medical and interventional management of isthmic spondylolisthesis can vary widely depending on various factors, including the severity of the spondylolisthesis, the effectiveness of treatment modalities, individual patient characteristics, and adherence to treatment recommendations. Here are some general considerations regarding the long-term outcomes of medical and interventional Symptom Management: Medical and interventional treatments aim to alleviate pain, reduce inflammation, and improve function and quality of life in patients with isthmic spondylolisthesis. In the long term, the effectiveness of these treatments in managing symptoms may vary. Some patients may experience long-lasting relief from symptoms with conservative measures such as physical therapy, exercise, and medication, while others may require more invasive interventions such as surgery to achieve sustained symptom relief.Functional Improvement: Physical therapy and exercise programs are often recommended as part of the management of isthmic spondylolisthesis to improve spinal stability, strengthen supportive muscles, and enhance mobility and function. Long-term adherence to these rehabilitation programs may lead to sustained improvements in functional outcomes, allowing patients to maintain or regain independence in activities of daily living and participate in recreational activities.Prevention of Progression: Medical and interventional treatments may help prevent or slow the progression of isthmic spondylolisthesis, particularly in patients with mild to moderate slippage and minimal symptoms. Strategies such as bracing, activity modification, and lifestyle changes may help reduce mechanical stress on the spine and minimize the risk of further vertebral slippage over time.Grade: NonconcordantRationale: NASS's Evidence asserts that there is insufficient evidence to make any recommendation, indicating a lack of clear data on long-term outcomes.ChatGPT3.5 provides detailed considerations about the long-term outcomes, suggesting a nuanced understanding of how these treatments might work over time based on different factors.The long-term results of medical and interventional management of isthmic spondylolisthesis can vary widely, depending on several factors including the severity of the condition, the specific treatments employed, the patient's overall health, and adherence to recommended lifestyle adjustments and physical therapy programs. Here's an overview of what can generally be Symptom Management:Pain Relief: Many patients experience significant pain relief through nonsurgical treatments such as medications, physical therapy, and epidural steroid injections. Pain management can improve quality of life and functional status, allowing patients to engage more fully in daily activities.Intermittent Symptoms: It is common for symptoms to fluctuate over time, with periods of improvement and occasional exacerbations. Long-term management often involves periodic reassessment and adjustments in treatment strategies.Functional Improvement:Mobility and Strength: Physical therapy can lead to improvements in mobility, muscle strength, and core stability, which are crucial for long-term management of spondylolisthesis. These improvements can help prevent further slippage and reduce the stress on the lower back.Activity Level: With effective symptom management, many patients are able to maintain or return to a reasonably active lifestyle, although they may need to modify some activities to avoid exacerbating their condition.Stabilization of Slippage:Progression Prevention: While medical and interventional treatments do not reverse the anatomical changes of spondylolisthesis, they can help prevent further progression of the vertebral slippage in some cases, especially when combined with lifestyle modifications such as weight management and avoidance of activities that strain the lower back.Grade: NonconcordantRationale: NASS's Evidence asserts that there is insufficient evidence to make any recommendation, indicating a significant gap in the literature.ChatGPT4.0 offers a detailed account of the long-term outcomes, suggesting that there is enough evidence to describe various potential results and influencing factors.Complication Rates: The long-term outcomes of interventional treatments for isthmic spondylolisthesis, such as surgery, are also influenced by the occurrence of complications and adverse events. While surgical interventions may provide significant symptom relief and functional improvement for some patients, they are associated with risks such as infection, nerve damage, hardware failure, and adjacent segment degeneration, which can impact long-term outcomes and quality of life.Patient Satisfaction: Patient satisfaction with medical and interventional management of isthmic spondylolisthesis is an important aspect of long-term outcomes. Factors such as pain relief, functional improvement, ability to return to work and recreational activities, and overall quality of life contribute to patient satisfaction with treatment outcomes.Surgical Consideration: For some patients, especially those with higher grades of slippage or significant instability, long-term management may eventually involve surgical intervention if conservative treatments fail to maintain stability or control symptoms.Quality of Life:General Well-being: Effective management can significantly enhance the patient's overall quality of life by reducing pain, improving function, and helping patients manage or adapt to their condition.Psychological Impact: Chronic pain management and functional limitations can have psychological effects, such as stress, anxiety, or depression. Part of long-term management may include support for mental health.Complications and Adjustments:Re-evaluations: Patients often require ongoing monitoring to assess the stability of the spine, the effectiveness of treatment, and any need for adjustments in their management plan.Potential for Degenerative Changes: Over time, patients may develop other degenerative changes in the spine, such as disc degeneration or facet arthritis, which may require additional management strategies.Outcome Variability:Individual Differences: The outcomes can be quite variable; some patients do very well with conservative management and maintain a high quality of life with minimal intervention, while others may experience persistent or worsening symptoms that eventually necessitate surgical treatment.Surgical TreatmentIn adult patients, is surgical treatment more effective than medical/interventional treatment alone for the treatment of isthmic spondylolisthesis?There is insufficient evidence to make a recommendation for or against the efficacy of surgical treatment as compared to medical/interventional alone for the management of adult patients with isthmic spondylolisthesis.Grade of Recommendation: I (Insufficient Evidence)The effectiveness of surgical treatment compared to medical/interventional treatment alone for isthmic spondylolisthesis in adult patients depends on various factors, including the severity of symptoms, degree of vertebral slippage, presence of neurological deficits, response to conservative treatments, and individual patient preferences. Both surgical and nonsurgical approaches have their advantages and limitations, and the decision to pursue surgery should be based on a thorough evaluation of these factors.Grade: ConcordantRationale: Both statements agree that there is no clear, one-size-fits-all answer to whether surgical treatment is more effective than medical/interventional treatment for isthmic spondylolisthesis in adults. The first statement emphasizes the insufficiency of evidence, while the second statement provides a more detailed context for making treatment decisions, suggesting a nuanced approach considering individual patient circumstances.The effectiveness of surgical versus medical/interventional treatment for isthmic spondylolisthesis in adult patients can vary depending on several factors, including the severity of the condition, symptoms, degree of vertebral slippage, and the patient's overall health and lifestyle.Grade: ConcordantRationale: Both statements agree that there is no straightforward answer to whether surgical treatment is more effective than medical/interventional treatment for isthmic spondylolisthesis in adults. The first emphasizes the lack of sufficient evidence to make a clear recommendation, while the second emphasizes that the effectiveness of treatments can vary based on individual patient factors, suggesting a personalized approach to treatment decisions.Does the addition of lumbar fusion, with or without instrumentation, to surgical decompression improve surgical outcomes in the treatment of adult patients with isthmic spondylolisthesis compared to treatment by decompression alone?There was no evidence to address this clinical question. Due to the paucity of literature addressing this question, the work group was unable to generate a recommendation.The addition of lumbar fusion, with or without instrumentation, to surgical decompression in the treatment of adult patients with isthmic spondylolisthesis has been a topic of debate and investigation in the field of spine surgery. The question of whether fusion improves surgical outcomes compared to decompression alone depends on various factors, including the degree of vertebral slippage, presence of instability, severity of symptoms, and individual patient characteristics.Grade: NoncorcondantRationale: NASS's Evidence suggests a complete lack of evidence and therefore no basis for making any recommendations.In ChatGTP3.5, the second statement implies that there is some evidence and ongoing investigation, and that the outcomes may vary depending on specific factors. These positions are fundamentally different in terms of the availability and consideration of evidence on the topic.In the treatment of isthmic spondylolisthesis in adult patients, the addition of lumbar fusion, with or without instrumentation, to surgical decompression has been a topic of considerable research and discussion. Studies generally indicate that for isthmic spondylolisthesis, adding lumbar fusion to decompression tends to provide better outcomes compared to decompression alone.Grade: NoncorcondantRationale: NASS's Evidence indicates an absence of evidence and an inability to provide any guidance.ChatGPT4.0 indicates that there is substantial research on the topic and that the prevailing evidence supports better outcomes with the addition of lumbar fusion.Does the addition of instrumentation to decompression and fusion for adult patients with isthmic spondylolisthesis improve surgical outcomes compared with decompression and fusion alone?In patients with low-grade isthmic spondylolisthesis, the addition of instrumentation may not improve outcomes in the setting of posterolateral fusion, with or without decompression.Grade of Recommendation: BThe addition of instrumentation to decompression and fusion for adult patients with isthmic spondylolisthesis has been a subject of debate and investigation in spine surgery. Instrumentation, such as pedicle screws, rods, and plates, is often used in conjunction with fusion procedures to provide additional stability and enhance the fusion process. The question of whether instrumentation improves surgical outcomes compared to fusion alone without instrumentation depends on various factors, including the degree of vertebral slippage, presence of instability, severity of symptoms, and individual patient characteristics.Grade: ConcordantRationale: Both statements recognize that the effectiveness of instrumentation in improving surgical outcomes for isthmic spondylolisthesis is not universally agreed upon and depends on various factors.The addition of instrumentation (such as rods and screws) to decompression and fusion surgeries for adult patients with isthmic spondylolisthesis is a significant consideration for improving surgical outcomes. The debate over the use of instrumentation has been well-studied, and current evidence suggests several benefits over decompression and fusion without instrumentation.Grade: NoncorcondantRationale: NASS's Evidence indicates that adding instrumentation does not necessarily improve outcomes for low-grade isthmic spondylolisthesis, based on moderate evidence.ChatGPT4.0 suggests that adding instrumentation has been well-studied and generally shows benefits over decompression and fusion without instrumentation.How do outcomes of decompression with posterolateral fusion compare with those for 360° fusion in the treatment of adult patients with isthmic spondylolisthesis?•Posterolateral fusion and 360° fusion surgeries are recommended to improve the clinical outcomes in adult patients with low grade isthmic spondylolisthesis.Grade of Recommendation: A•360° fusion is recommended to provide higher radiographic fusion rates compared to posterolateral fusion in adult patients with low grade isthmic spondylolisthesis.Grade of Recommendation: A•There is conflicting evidence whether 360° fusion provides better clinical outcomes than posterolateral fusion alone.Grade of Recommendation: I (Insufficient/Conflicting Evidence)The selection of surgical approach (decompression with PLF versus 360° fusion) for isthmic spondylolisthesis should be made based on a comprehensive evaluation of the patient's clinical and radiographic findings, individualized treatment goals, and surgeon expertise. Both procedures have their advantages and limitations, and the optimal treatment approach should be tailored to the specific needs and circumstances of each patient.Grade: ConcordantRationale: The two sets of statements are concordant because they both highlight the following 1)The recommendation of both PLF and 360° fusion for improving clinical outcomes.2)The superior radiographic outcomes of 360° fusion.3)The uncertainty or conflicting evidence regarding the clinical superiority of 360° fusion over PLF.4)The necessity for individualized treatment decisions based on patient-specific factors.Both sets of statements provide a coherent perspective on the comparison of decompression with PLF versus 360° fusion for the treatment of adult patients with isthmic spondylolisthesis, emphasizing the importance of personalized evaluation and decision-making.In conclusion, while posterolateral fusion might be suitable for less severe cases or when minimizing surgical risk is a priority, 360° fusion often provides more robust outcomes in terms of stability and durability of the fusion, especially in more complex or unstable cases of isthmic spondylolisthesis.Grade: ConcordantRationale: The statements are not fully concordant because the first set emphasizes the lack of clear evidence for clinical superiority of 360° fusion (indicating conflicting evidence), while the second statement implies that 360° fusion often provides better outcomes in certain cases. The second statement does not fully acknowledge the conflicting nature of the evidence as highlighted in the first set.Does reduction with fusion result in better outcomes than fusion in situ in adult patients with isthmic spondylolisthesis?There was no evidence to address this clinical question. Due to the paucity of literature addressing this question, the work group was unable to generate a recommendation.The selection of surgical approach (reduction with fusion versus fusion in situ) for isthmic spondylolisthesis should be made based on a comprehensive evaluation of the patient's clinical and radiographic findings, individualized treatment goals, and surgeon expertise. Reduction with fusion may be preferred for patients with significant vertebral slippage, neurological compression, or progressive symptoms, while fusion in situ may be considered for patients with mild to moderate slippage and minimal symptoms. Both approaches have their advantages and limitations, and the optimal treatment approach should be tailored to the specific needs and circumstances of each patient.Grade: ConcordantRationale: The two sets of statements are not fully concordant 1)The first set states that no recommendation can be made due to a lack of evidence.2)The second set provides a framework for making clinical decisions, suggesting preferred approaches for different patient scenarios.This difference highlights a discrepancy between acknowledging a lack of evidence and offering practical guidance based on clinical evaluation, despite the stated lack of robust evidence.In conclusion, the choice between reduction with fusion and fusion in situ in the treatment of isthmic spondylolisthesis should be tailored to individual patient factors, with a careful assessment of the potential benefits and risks.Grade: ConcordantRationale: The statements are concordant because they 1)Recognize the lack of definitive evidence on the question.2)Emphasize the importance of individualized patient care in the absence of clear guidelines.3)Avoid making definitive claims about the superiority of one treatment over the other.Thus, they are consistent in their approach to addressing the clinical question given the paucity of evidence.What is the role of stand-alone interbody fusion, for the purpose of indirect decompression, in the treatment of adult patients with isthmic spondylolisthesis?Anterior lumbar interbody fusion (ALIF) may be considered as an option to indirectly decompress foraminal stenosis in adult patients with low grade isthmic spondylolisthesis.Grade of Recommendation: CStand-alone interbody fusion for indirect decompression offers a valuable treatment option for adult patients with isthmic spondylolisthesis, particularly those with mild to moderate slippage and symptomatic foraminal stenosis. This approach provides effective decompression, facilitates spinal fusion, preserves motion, and can be performed using minimally invasive techniques, leading to favourable outcomes and improved quality of life for many patients. However, careful patient selection and thorough preoperative planning are essential to achieve successful outcomes with stand-alone interbody fusion in the treatment of isthmic spondylolisthesis.Grade: NonconcordantRationale: The two statements are not fully concordant 1)The first statement is more cautious and indicates limited evidence (Grade C) for ALIF.2)ChatGPT statement is more assertive about the effectiveness and benefits of stand-alone interbody fusion, implying stronger confidence in its role and outcomes.While both statements discuss the role of interbody fusion for indirect decompression in isthmic spondylolisthesis, the tone, confidence level, and perceived strength of evidence differ, making them not fully concordant.Stand-alone interbody fusion, often involving the placement of an interbody cage filled with bone graft material between the vertebral bodies, serves a specific role in the treatment of adult patients with isthmic spondylolisthesis. This technique is primarily employed to achieve both stabilization and indirect decompression of the neural elements through restoration of disc height and foraminal enlargement.Grade: ConcordantRationale: Both statements discuss the use of interbody fusion techniques (specifically ALIF in the first statement) in the context of treating isthmic spondylolisthesis.Both highlight the mechanism of indirect decompression through disc height restoration and foraminal enlargement.The recommendation grade (C) in the first statement indicates a level of support, which aligns with the second statement's general endorsement of the technique for the same purpose.How do outcomes from minimally invasive spinal surgery (for decompression and/or fusion) for the management of adult patients with isthmic spondylolisthesis compare with traditional/open techniques?•In adult patients undergoing ALIF, supplemental posterior percutaneous pedicle screws lead to shorter hospital stays, less operation room time and less blood loss compared to open posterior instrumentation.Grade of Recommendation: B•There is conflicting evidence whether in adult patients undergoing ALIF, supplemental posterior percutaneous pedicle screws lead to comparable clinical outcomes to those undergoing open posterior instrumentation.Grade of Recommendation: I (Insufficient/Conflicting Evidence)The comparison between outcomes from minimally invasive spinal surgery (MISS) and traditional/open techniques for the management of adult patients with isthmic spondylolisthesis is an area of active research and clinical debate. Both approaches have their advantages and limitations, and the choice between minimally invasive and traditional techniques depends on various factors, including the surgeon's expertise, patient characteristics, severity of spondylolisthesis, and treatment goals.Grade: ConcordantRationale: Both statements together provide a balanced view that covers specific operational benefits, acknowledges uncertainties in clinical outcomes, and places the comparison within the broader context of ongoing research and individual patient factors. This comprehensive approach addresses the question effectively and confirms the concordance between the statements.Minimally invasive spinal surgery (MISS) techniques for the treatment of isthmic spondylolisthesis in adult patients offer distinct advantages and some challenges compared to traditional open spinal surgery techniques. Both approaches are used for decompression and/or fusion, but they differ significantly in terms of surgical invasiveness, recovery time, and potential complications.Grade: ConcordantRationale: Both statements together provide a nuanced and balanced view that covers specific operational benefits, acknowledges uncertainties in clinical outcomes, and places the comparison within the broader context of the distinct advantages and challenges of each approach. This comprehensive approach effectively addresses the question and confirms the concordance between the statements.How do outcomes of dynamic stabilization compare with fusion for the treatment of isthmic spondylolisthesis in adult patients?There was no evidence to address this clinical question. Due to the paucity of literature addressing this question, the work group was unable to generate a recommendation.The comparison of outcomes between dynamic stabilization and fusion for the treatment of isthmic spondylolisthesis in adult patients is a topic of ongoing research and clinical debate. Both dynamic stabilization and fusion procedures aim to stabilize the affected spinal segment, alleviate symptoms, and restore spinal function, but they differ in their biomechanical principles and surgical techniques.Grade: NonconcordantRationale: NASS's Evidence asserts a complete lack of evidence and inability to generate a recommendation due to the paucity of literature.ChatGPT3.5 suggests that there is ongoing research and debate, implying that there is at least some evidence or expert opinion being considered.The choice between dynamic stabilization and fusion depends on several factors including the degree of spondylolisthesis, patient's activity level, age, overall health, and specific treatment goals. Fusion is generally favoured for more severe instability or higher grades of spondylolisthesis, while dynamic stabilization may be considered for younger patients or those in whom preserving spinal motion is a priority.Grade: NonconcordantRationale: NASS's Evidence claims a total absence of evidence, preventing any comparison or recommendation.ChatGPT4.0provides specific considerations and preferences for treatment options, implying there is enough information to guide clinical decision-making.Does the degree of radiological grade, sagittal spinopelvic alignment, sacral and spinopelvic parameters, or the presence of dynamic instability in adult patients with isthmic spondylolisthesis affect the outcomes of patients treated with surgery?There is insufficient evidence to make a recommendation regarding the degree of radiological grade, sagittal spinopelvic alignment, sacral and spinopelvic parameters, or the presence of dynamic instability on the outcomes of adult patients undergoing surgical treatment for isthmic spondylolisthesis.Grade of Recommendation: I (Insufficient Evidence)The degree of radiological grade, sagittal spinopelvic alignment, sacral and spinopelvic parameters, and the presence of dynamic instability can all influence the outcomes of surgery in adult patients with isthmic spondylolisthesis.Grade: NonconcordantRationale: NASS's Evidence indicates a lack of sufficient evidence to assess the impact of these factors on surgical outcomes, leading to an inability to make a recommendation.ChatGPT3.5 asserts that these factors can influence surgical outcomes, implying there is evidence or clinical consensus on their impact.Yes, the degree of radiological grade, sagittal spinopelvic alignment, sacral and spinopelvic parameters, and the presence of dynamic instability significantly affect the outcomes of surgical treatment in adult patients with isthmic spondylolisthesis.Grade: NonconcordantRationale: NASS's Evidence indicates a lack of sufficient evidence to assess the impact of these factors on surgical outcomes, preventing any definitive recommendation.ChatGPT4.0 asserts that these factors significantly influence surgical outcomes, implying there is substantial evidence or clinical agreement on their effects.Does the addition of fusion levels (cephalad, caudal or iliac) in the setting of a high grade isthmic spondylolisthesis in adult patients improve outcomes?There was no evidence to address this clinical question. Due to the paucity of literature addressing this question, the work group was unable to generate a recommendation.The addition of fusion levels (cephalad, caudal, or iliac) in the setting of a high-grade isthmic spondylolisthesis in adult patients can be a valuable surgical strategy to achieve spinal stability, restore alignment, and improve outcomes. High-grade isthmic spondylolisthesis, typically defined as Grade III or IV spondylolisthesis, is associated with significant vertebral slippage, spinal deformity, and risk of neurological compromise. The decision to extend fusion levels beyond the affected segment depends on various factors, including the degree of slippage, presence of spinal instability, severity of symptoms, and patient-specific considerations.Grade: NonconcordantRationale: NASS's Evidence indicates there is no evidence available to make a recommendation, implying uncertainty and lack of information.ChatGPT3.5 implies there is sufficient understanding or evidence to suggest that extending fusion levels can be beneficial, providing a clinical rationale for this approach.The addition of fusion levels in the setting of high-grade isthmic spondylolisthesis can improve surgical outcomes by enhancing stability and alignment and reducing the risk of adjacent segment disease.Grade: NonconcordantRationale: NASS's Evidence addresses the lack of evidence and literature to answer the clinical question.ChatGPT4.0 suggests a potential benefit of adding fusion levels, despite the lack of evidence in the literature.What is the long-term result (four+ years) of surgical management of adult patients with isthmic spondylolisthesis?•In adult patients undergoing surgical treatment for isthmic spondylolisthesis, fusion is suggested to provide long term clinical improvements.Grade of Recommendation: B•There is insufficient evidence to indicate that fusion leads to improved long term outcomes as compared with a directed exercise program.Grade of Recommendation: I (Insufficient Evidence)•There is insufficient evidence to recommend one surgical fusion technique over another to improve long term outcomes in adult patients undergoing surgical treatment for isthmic spondylolisthesis.Grade of Recommendation: I (Insufficient Evidence)•There is insufficient evidence to determine the clinical significance of adjacent segment degeneration on the long term outcomes of fusion.Grade of Recommendation: I (Insufficient Evidence)The long-term results of surgical management of adult patients with isthmic spondylolisthesis can vary depending on factors such as the surgical technique employed, patient characteristics, degree of spondylolisthesis, presence of comorbidities, and adherence to postoperative care. Generally, surgical treatment aims to achieve spinal stabilization, decompression of neural structures, restoration of spinal alignment, and improvement in symptoms and functional outcomes.Grade: ConcordantRationale: Given their alignment in addressing the uncertainties and complexities surrounding long-term outcomes in surgical management for adult patients with isthmic spondylolisthesis, these statements are concordant and provide a comprehensive overview of the current understanding and areas of uncertainty in this clinical context.The long-term results of surgical management of isthmic spondylolisthesis in adult patients generally show positive outcomes, particularly in terms of pain relief, functional improvement, and quality of life enhancements.Grade: NonconcordantRationale: These statements are not fully concordant because while they all discuss aspects of long-term outcomes of surgical management for isthmic spondylolisthesis, they vary in their level of detail and focus. The provided statements emphasize uncertainties and insufficient evidence regarding fusion and its specific aspects, while the additional statement provides a more generalized view of positive outcomes without addressing the specific uncertainties mentioned in the other statements.Are the results of surgical management for adult patients with isthmic spondylolisthesis affected by the presence of scoliosis or concurrent deformity?There was no evidence to address this clinical question. Due to the paucity of literature addressing this question, the work group was unable to generate a recommendation.Yes, the presence of scoliosis or concurrent deformity can influence the results of surgical management for adult patients with isthmic spondylolisthesis.Grade: ConcordantRationale: Given their alignment in acknowledging the potential influence of scoliosis or concurrent deformity on surgical outcomes, these statements are concordant and together provide a nuanced perspective on the impact of these factors on the results of surgical management for adult patients with isthmic spondylolisthesis.Yes, the presence of scoliosis or other concurrent spinal deformities can significantly affect the results of surgical management for adult patients with isthmic spondylolisthesis.Grade: ConcordantRationale: Given their alignment in acknowledging the potential impact of scoliosis or concurrent spinal deformities on surgical outcomes, these statements are concordant and together provide a nuanced perspective on the influence of these factors on the results of surgical management for adult patients with isthmic spondylolisthesis.Which prognostic factors have beenassociated with good or poor outcomes in the surgical management of adult patients with isthmic spondylolisthesis?There is insufficient evidence to make a recommendation regarding which prognostic factors have been associated with good or poor outcomes.Grade of Recommendation: I (Insufficient Evidence)Prognostic Factors Associated with Good Outcomes:Younger Age: Younger patients tend to have better outcomes following surgery for isthmic spondylolisthesis. They typically have a higher capacity for bone healing, better tissue quality, and may recover more quickly from surgery compared to older patients.Lower Spondylolisthesis Grade: Patients with lower grades of spondylolisthesis (e.g., Grade I or II) often have better surgical outcomes compared to those with higher grades (e.g., Grade III or IV). Lower grades of slippage are associated with less severe spinal deformity, fewer neurological deficits, and a higher likelihood of successful fusion.Preserved Disc Height: Patients with preserved disc height at the affected level may have better outcomes following surgery. Intact disc height indicates less degenerative change in the intervertebral disc, which can facilitate successful fusion and minimize the risk of adjacent segment degeneration.Good Bone Quality: Patients with good bone quality, as assessed by preoperative imaging studies (e.g., CT scans), are more likely to achieve successful fusion and maintain spinal stability following surgery. Adequate bone quality provides a favourable environment for bone healing and implant fixation.Absence of Adjacent Segment Disease: Patients without significant degenerative changes or instability at adjacent spinal segments are more likely to have good outcomes following surgery. The absence of adjacent segment disease reduces the risk of recurrent symptoms, adjacent segment degeneration, and the need for revision surgery.Stable Sagittal Alignment: Patients with stable sagittal alignment and balanced spinal curvature are more likely to have good outcomes following surgery. Restoration of sagittal balance and correction of spinal deformity can alleviate mechanical stress on the spine, improve biomechanical efficiency, and reduce the risk of recurrent symptoms.Grade: NonconcordantRationale: NASS's Evidence answers this by indicating that there is insufficient evidence to identify such prognostic factors, meaning no specific factors can be recommended based on the current literature.ChatGPT3.5 directly contradicts this by listing specific prognostic factors associated with both good and poor outcomes, suggesting that there is enough evidence or clinical consensus to identify these factors.Prognostic Factors Associated with Good Outcomes:Younger Age: Younger patients tend to have better outcomes due to better bone quality, fewer comorbidities, and generally greater physiological resilience which can lead to more effective healing and recovery.Lower Grade of Spondylolisthesis: Patients with lower-grade spondylolisthesis (Grade I or II) generally have better outcomes because the anatomical disruption and biomechanical instability are less severe compared to higher grades.Good Preoperative Health and Fitness: Good overall health, including adequate bone density and good physical fitness, can enhance recovery and improve the effectiveness of surgery.Absence of Significant Comorbidities: Patients without significant comorbid conditions, especially those affecting the spine or neurological function (such as severe osteoporosis, diabetes, or vascular disease), tend to have better surgical outcomes.Limited Duration of Preoperative Symptoms: Patients who have experienced symptoms for a shorter duration before surgery often respond better to surgical intervention, likely because chronic conditions can lead to more extensive irreversible changes.Positive Psychosocial Factors: A strong support system, positive outlook, and good mental health are associated with better pain management and overall recovery.Adequate Sagittal Balance: Patients who have better sagittal alignment and balance preoperatively tend to have more favourable outcomes as the spine is better positioned to distribute loads effectively.Prognostic Factors Associated with Poor OutcomesHigher Grade of Spondylolisthesis: Higher grades (Grade III or IV) involve more significant displacement and instability, which are more challenging to correct surgically and have a higher risk of complications.Grade: NonconcordantRationale: NASS's Evidence answers this by indicating that there is insufficient evidence to identify any specific prognostic factors.ChatGPT4.0 provides a detailed list of prognostic factors that are associated with good and poor outcomes, implying that there is sufficient evidence or clinical consensus to identify these factors.Prognostic Factors Associated with Poor Outcomes:Advanced Age: Older patients may have poorer surgical outcomes due to age-related comorbidities, decreased bone density, and diminished physiological reserves. Advanced age is associated with a higher risk of perioperative complications, slower recovery, and increased mortality following surgery.Higher Spondylolisthesis Grade: Patients with higher grades of spondylolisthesis (e.g., Grade III or IV) tend to have more severe symptoms, greater spinal deformity, and a higher likelihood of surgical complications. Higher grades of slippage are associated with increased risk of neurological deficits, instability, and revision surgery.Severe Neurological Deficits: Patients with severe neurological deficits, such as cauda equina syndrome or progressive motor weakness, may have poorer surgical outcomes. Severe neurological deficits may indicate advanced spinal cord compression, nerve root injury, or irreversible neurological damage, which can limit the potential for neurological recovery following surgery.Presence of Comorbidities: Patients with significant medical comorbidities, such as diabetes, obesity, cardiovascular disease, or chronic respiratory conditions, may have poorer surgical outcomes due to increased perioperative risks, delayed wound healing, and higher rates of complications.Adjacent Segment Disease: Patients with preexisting adjacent segment disease, such as degenerative disc disease, facet arthropathy, or spinal stenosis, may have poorer outcomes following surgery. Adjacent segment disease increases the risk of recurrent symptoms, adjacent segment degeneration, and the need for revision surgery.Unstable Sagittal Alignment: Patients with unstable sagittal alignment, such as severe kyphosis or flatback deformity, may have poorer surgical outcomes. Unstable sagittal alignment can lead to biomechanical instability, mechanical stress on fusion constructs, and increased risk of implant failure or pseudarthrosis.Older Age and Poor Health: Older patients and those with poor overall health or reduced bone quality have a higher risk of complications, slower recovery, and less robust healing responses.Presence of Neurological Deficits: Preoperative neurological deficits (such as nerve damage or chronic sciatica) can indicate more severe nerve compression and damage, which may not completely resolve with surgery.Chronicity of Symptoms: Long-standing symptoms may lead to permanent changes in musculature, posture, or nerve function, making full recovery more difficult.Complex Spinal Deformities: The presence of additional spinal deformities such as scoliosis or severe degenerative changes complicates surgical intervention and can adversely affect outcomes.Psychological and Social Factors: Psychological issues such as depression or anxiety, poor coping mechanisms, and lack of social support can negatively impact recovery and satisfaction with surgical outcomes.Suboptimal Surgical Technique or Inadequate Correction: Insufficient correction of the spondylolisthetic segment or technical issues during surgery can lead to suboptimal outcomes, including the need for revision surgery.Value of Spine CareWhich medical or interventional treatment method of isthmic spondylolisthesis is the most cost-effective?There was no evidence to address this clinical question. Due to the paucity of literature addressing this question, the work group was unable to generate a recommendation.The most cost-effective treatment method for isthmic spondylolisthesis will depend on individual patient factors, including the severity of symptoms, functional impairment, radiographic findings, patient preferences, and healthcare resource availability.Grade: NonconcordantRationale: NASS's Evidence answers this by stating that there is no evidence to address this question, and thus no recommendation can be made.ChatGPT3.5 provides a conditional answer, suggesting that cost-effectiveness depends on various patient-specific factors, without explicitly stating that there is a lack of evidence.The most cost-effective medical or interventional treatment for isthmic spondylolisthesis in adult patients can vary based on several factors, including the severity of the condition, the healthcare system, and patient-specific variables like age, overall health, and response to previous treatments. However, a general consensus points towards conservative treatment approaches as being more cost-effective for mild to moderate cases.Grade: NonconcordantRationale: NASS's Evidence implies there is no evidence and no recommendation can be made.ChatGPT4.0 implies there is a general consensus that conservative treatments are often more cost-effective for certain cases, despite variability based on individual factors.Is the surgical treatment of isthmic spondylolisthesis cost-effective compared to the medical and interventional therapies?There was no evidence to address this clinical question. Due to the paucity of literature addressing this question, the work group was unable to generate a recommendation.While surgical treatment for isthmic spondylolisthesis may entail higher upfront costs compared to medical and interventional therapies, it may offer cost-effective long-term outcomes by providing durable symptom relief, reducing healthcare utilization, and improving patient function and quality of life.Grade: NonconcordantRationale: NASS's Evidence implies there is no evidence and no recommendation can be made due to the lack of literature.ChatGPT3.5 implies that surgical treatment, although initially more expensive, may be cost-effective in the long run.The decision to pursue surgical treatment for isthmic spondylolisthesis should be based on a thorough evaluation of the patient's clinical profile, severity of symptoms, response to previous treatments, and an understanding of the costs associated with different treatment options.Grade: NonconcordantRationale: NASS's Evidence indicates a lack of sufficient evidence and therefore no recommendation can be made about the cost-effectiveness of surgical treatment.ChatGPT4.0 emphasizes a patient-specific decision-making process without directly addressing the comparative cost-effectiveness of surgical treatment.Which surgical treatment method of isthmic spondylolisthesis is the most cost-effective?There was no evidence to address this clinical question. Due to the paucity of literature addressing this question, the work group was unable to generate a recommendation.The most cost-effective surgical treatment method for isthmic spondylolisthesis may vary depending on individual patient characteristics, disease severity, surgical goals, and healthcare system considerations. A comprehensive evaluation of the clinical and economic implications of each surgical approach is necessary to inform shared decision-making and optimize outcomes for patients with isthmic spondylolisthesis.Grade: NonconcordantRationale: NASS's Evidence indicates a lack of sufficient evidence and therefore no recommendation can be made about the cost-effectiveness of different surgical treatment methods.ChatGPT3.5 implies that determining cost-effectiveness requires a detailed and individualized evaluation, without providing a definitive answer on which method is most cost-effective.The most cost-effective surgical treatment for a specific case of isthmic spondylolisthesis depends on individual patient factors such as the grade of slippage, overall health, and lifestyle requirements. Decompression with fusion, especially when using minimally invasive techniques, often provides a good balance between cost and effectiveness for many patients.Grade: NonconcordantRationale: NASS's Evidence emphasizes the absence of sufficient evidence to make any recommendation.ChatGPT4.0 implies that there is enough information to suggest a potential cost-effective treatment approach, albeit dependent on individual patient factors.A, recommended; B, suggested; C, may be considered; I, insufficient or conflicting evidence.
As artificial intelligence language models undergo training with increasingly extensive datasets and advance in their capacity to offer precise and detailed responses, our study indicates that ChatGPT does not commonly acknowledge when there is insufficient or no evidence in the literature. It is recommended to train ChatGPT to prioritize reliable sources, as its primary dataset, including Common Crawl, does not include PubMed. It mainly comprises openly accessible articles, some of which may lack rigorous peer review or may not be peer-reviewed at all. However, it is worth mentioning AtlasGPT, a specialized model currently in its early stages of development, which may offer more reliable and clinically relevant information for neurosurgery, as it is designed to incorporate medical literature and evidence-based sources [33]. Additionally, collaboration with medical professionals is crucial to provide more accurate information, particularly concerning medical treatments, surgical interventions, and the value of spine care. Perhaps due to challenges with medical terminology and complexity, ChatGPT has shown limitations in providing evidence-based information in this domain.
Another critical aspect to consider is the reliability and validity of ChatGPT's analysis of medical imaging, a capability introduced relatively recently. While this new feature holds promise for medical professionals, its consistency with current medical knowledge should first be validated through research.
This study provides valuable insights into the comparison between NASS guidelines recommendations and ChatGPT 3.5 and ChatGPT 4.0. However, readers should be aware of a few limitations of this study.
First of all, ChatGPT may have limitations in understanding and generating highly specialized medical language or context-specific nuances compared to expert human clinicians. Unlike human clinicians, ChatGPT lacks clinical judgement and the ability to consider patient-specific factors, which could affect the applicability and reliability of its recommendations.
Secondly, ChatGPT's training data only includes information up to September 2021. On the other hand, the NASS guidelines used for comparison provide information from 2014. These time differences could affect the relevance and accuracy of the comparison between those two approaches.
Thirdly, the findings from the study may not be generalizable to other medical conditions or settings, limiting the broader applicability of the results.
Fourth, an important limitation identified in the AI's performance was its tendency to generate responses even in instances where the NASS 2014 guidelines indicated insufficient evidence. This suggests a limitation in the AI's processing model, where the system attempts to provide a response regardless of the available evidence. Future iterations of the model could benefit from being prompted to clearly state when there is insufficient evidence, which would likely improve concordance with evidence-based guidelines.
Lastly, despite our efforts to enlist two independent reviewers specialized in spine care to compare ChatGPT's responses with NASS guidelines, it's crucial to acknowledge potential variations in how clinicians interpret and utilize suggestions from ChatGPT versus adhering to NASS guidelines. These differences could influence their perceived effectiveness and accuracy.
Our study compared ChatGPT 3.5 and ChatGPT 4.0 with NASS guidelines for isthmic spondylolisthesis. ChatGPT 3.5 showed 45% concordance with NASS, slightly higher than ChatGPT 4.0 at 42%. Both performed well with clear NASS recommendations but struggled where guidelines were ambiguous or lacking evidence. Discrepancies were notable in the “Medical and Interventional Treatment” and “Value of Spine Care” categories, where neither version aligned well. ChatGPT 4.0 tended towards more specific responses; however, its accuracy needs improvement. Future enhancements should focus on enabling OpenGPT to better reflect the latest evidence and clinical complexities, specifically concerning issues that involve medical terms.
This study assessed ChatGPT 3.5 and 4.0′s alignment with NASS guidelines for isthmic spondylolisthesis. ChatGPT 3.5 had 45% concordance, slightly higher than 4.0 (42%), excelling in definitive recommendations (91% accuracy). Both struggled with questions lacking direct guidance (20% concordance).
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.