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Lumbar degenerative spondylolisthesis: role of sagittal alignment

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Abstract

Purpose

To evaluate the sagittal alignment of the lumbar spine in patients with degenerative spondylolisthesis at the L4-5 level.

Methods

Patients with untreated degenerative spondylolisthesis at L4-5 were retrospectively identified from the clinical practice of spine surgeons at an academic medical center. All patients had standing X-rays that were reviewed by the senior surgeon to confirm the presence of degenerative spondylolisthesis at L4-5. Radiographs were analyzed for the following: lumbar lordosis (LL), lower lumbar lordosis (L4-S1; LLL), L5-S1 lordosis, pelvic incidence (PI), and pelvic tilt (PT). From these measurements, lumbar distribution index (LLL/LL × 100; LDI), ideal lumbar lordosis (PI × 0.62 + 29; ILL), PI-LL mismatch, and relative lumbar lordosis (LL-ILL; RLL) were calculated. These parameters were used to evaluate the sagittal alignment of the lumbar spine. Normal alignment was defined based on previous studies and clinical experience.

Results

117 participants met inclusion criteria, with an average age of 67.2 years. The majority of the cohort demonstrated hypolordotic sagittal alignment of the L5-S1 segment when assessed in relation to ILL, PI, and LL (73.5%, 61.5%, and 50.4% respectively). Evaluation of the lower lumbar spine (L4-S1) demonstrated normal sagittal alignment when evaluated via LDI and LLL (65%, 52.1%, respectively), suggesting the presence of compensatory hyperextension at L4-5 in response to the L5-S1 hypolordosis. Consequently, normal sagittal alignment of the regional lumbar spine was maintained when evaluated using LL, PI-LL mismatch, and RLL (51.3%, 47%, and 62.4% respectively).

Conclusions

This study demonstrates that there is a high incidence of relative hypolordosis at the L5-S1 level among patients who present with degenerative spondylolisthesis at L4-5. The L5-S1 hypolordosis is associated with L4-5 hyperlordosis, such that the lower lumbar lordosis (L4-S1; LLL) and regional lumbar lordosis (LL) are still within normal range. It is probable that L5-S1 hypolordosis was the initial pathologic event that incited compensatory L4-5 hyperlordosis, which in turn may have led to facet degeneration and laxity, and eventually to development of spondylolisthesis.

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Acknowledgements

Thank you to Paul Lender for helping evaluate intra-class correlation coefficients (ICCs) statistics.

Funding

No funding was required for this project.

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Authors and Affiliations

  1. Department of Orthopedic Surgery, University of Minnesota, 2512 South 7th Street, Suite R200, Minneapolis, MN, 55455, USA

    Gurmit Singh, Jonathan N. Sembrano, Jason J. Haselhuhn & David W. Polly Jr.

  2. Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA

    David W. Polly Jr.

Authors
  1. Gurmit Singh
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  2. Jonathan N. Sembrano
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Contributions

GS, JNS: Made substantial contributions to the conception and design of the work, and the acquisition, analysis, and interpretation of data. Revised the work critically for important intellectual content. Approved the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. JJH: Made substantial contributions to the analysis and interpretation of data. Revised the work critically for important intellectual content. Approved the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. DWP: Made substantial contributions to the conception and design of the work, and the acquisition, analysis, and interpretation of data. Revised the work critically for important intellectual content. Approved the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Corresponding author

Correspondence to Gurmit Singh.

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Conflict of interest

David W. Polly Jr.: Consultant for SI-Bone, Globus Medical, and Alexion, Royalties Springer (textbook), Research support from MizuhoOSI and Medtronic to my institution, Royalities from Globus Medical and Medtronic to my Institution, Speaker for Globus Medical. Jonathan N. Sembrano: Research support from Nuvasive, Orthofix, and AO spine to my institution. Gurmit Singh: None.

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Institutional review board (IRB) approval for this project was obtained from the University of Minnesota IRB.

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Singh, G., Sembrano, J.N., Haselhuhn, J.J. et al. Lumbar degenerative spondylolisthesis: role of sagittal alignment. Spine Deform 12, 443–449 (2024). https://doi.org/10.1007/s43390-023-00788-6

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