Recently, the etiology and development of lumbar degenerative spondylolisthesis have been reported to be influenced by the sagittal spinopelvic complex.1,2 Nevertheless, sagittal spinopelvic profiles involving anterior and posterior spondylolisthesis (i.e., anterolisthesis and retrolisthesis) remain unclear. We hypothesized that the direction of the lumbar degenerative spondylolisthesis is influenced by the level of the apex of lumbar lordosis.
We conducted a retrospective radiographic study on patients with lumbar degenerative spondylolisthesis to investigate the relationship between the direction of the lumbar degenerative spondylolisthesis and the level of the apex of the lumbar lordosis (registration number: 2020-04-R-11). Of 305 consecutive patients with a diagnosis of lumbar degenerative spondylolisthesis who underwent standardized lateral standing and deep-seated spinopelvic radiographic examinations at our institution between January 2010 and May 2014, 282 patients (31 male and 251 female; average age, 65.7 years) were considered eligible for this study. The exclusion criteria included patients with a history of spinal surgery (4 patients) and those with a lack of available data (19 patients). Spondylolisthesis was defined as a slippage of >3 mm on either of the two spinopelvic radiographs.3 The level of lumbar degenerative spondylolisthesis was identified as the most severe slippage as measured by the Newman classification.2 Patients were divided into two groups: anterolisthesis and retrolisthesis (Table 1).
Table 1.
Patient demographics, level of spondylolisthesis, apex of lumbar lordosis, and level of spondylolisthesis assessed relative to the apex of lumbar lordosis by the direction of lumbar degenerative spondylolisthesis.
| Anterolisthesis (n = 233) | Retrolisthesis (n = 49) | p value | |
|---|---|---|---|
| Patient demographics | |||
| Sex (male/female ratio) | 23/210 | 8/41 | 0.189 |
| Age (years)* | 65.3 ± 9.8 (44–92) | 67.3 ± 9.8 (49–88) | 0.203 |
| Body mass index (kg/m2)* | 24.5 ± 3.6 (18.0–37.7) | 24.0 ± 3.2 (18.8–32.3) | 0.322 |
| Level of spondylolisthesis | |||
| L1 vertebra, n (%) | 0 (0) | 4 (8.2) | <0.001 |
| L2 vertebra, n (%) | 1 (0.4) | 17 (34.7) | <0.001 |
| L3 vertebra, n (%) | 43 (18.5) | 23 (46.9) | <0.001 |
| L4 vertebra, n (%) | 170 (73.0) | 5 (10.2) | <0.001 |
| L5 vertebra, n (%) | 19 (8.1) | 0 (0) | 0.038 |
| Apex of lumbar lordosis | |||
| Thoracic spine, n (%) | 11 (4.7) | 1 (2.0) | 0.398 |
| Th12/L1 intervertebral disc, n (%) | 2 (0.9) | 0 (0) | 0.515 |
| L1 vertebra, n (%) | 3 (1.3) | 0 (0) | 0.425 |
| L1/2 intervertebral disc, n (%) | 6 (2.6) | 1 (2.0) | 0.827 |
| L2 vertebra, n (%) | 11 (4.7) | 0 (0) | 0.121 |
| L2/3 intervertebral disc, n (%) | 34 (14.6) | 0 (0) | 0.004 |
| L3 vertebra, n (%) | 64 (27.5) | 1 (2.0) | <0.001 |
| L3/4 intervertebral disc, n (%) | 61 (26.2) | 11 (22.4) | 0.586 |
| L4 vertebra, n (%) | 38 (16.3) | 12 (24.5) | 0.173 |
| L4/5 intervertebral disc, n (%) | 1 (0.4) | 11 (22.4) | <0.001 |
| L5 vertebra, n (%) | 2 (0.8) | 9 (18.4) | <0.001 |
| L5/S1 intervertebral disc, n (%) | 0 (0) | 3 (6.1) | <0.001 |
| Level of spondylolisthesis assessed relative to the apex of lumbar lordosis | |||
| Low, n (%) | 179 (76.8) | 2 (4.1) | <0.001 |
| Middle, n (%) | 47 (20.2) | 0 (0) | <0.001 |
| High, n (%) | 7 (3.0) | 47 (95.9) | <0.001 |
Low was defined as spondylolysis at a level lower than the apex of lumbar lordosis. Middle was defined as spondylolysis of the apex of lumbar lordosis. High was defined as spondylolysis at a level higher than the apex of lumbar lordosis. *Values are expressed as mean ± standard deviation (range).
The apex of lumbar lordosis was defined as the most anterior lumbar vertebra or intervertebral disc from the gravity line on a lateral standing spinopelvic radiograph.4 The level of the lumbar degenerative spondylolisthesis assessed relative to the apex of lumbar lordosis was defined as follows: lower than the apex of lumbar lordosis (low), the apex of lumbar lordosis (middle), or higher than the apex of lumbar lordosis (high).
Student's t-test was used to compare quantitative data (i.e., age and body mass index) between the anterolisthesis and retrolisthesis groups. Further, χ2 test was used to compare qualitative data (i.e., sex, level of the spondylolisthesis, the apex of lumbar lordosis, and level of the spondylolisthesis assessed relative to the apex of lumbar lordosis) between the groups. The level of significance (p value) was set at 0.05.
The anterolisthesis group showed more “low” spondylolisthesis (179/233 patients [76.8%] vs. 2/49 patients [4.1%], p < 0.001) and “middle” spondylolisthesis (47/233 patients [20.2%] vs. 0/49 patients [0%], p < 0.001) than the retrolisthesis group. Conversely, the retrolisthesis group had more “high” spondylolisthesis (7/233 patients [3.0%] vs. 47/49 patients [95.9%], p < 0.001) than the anterolisthesis group.
We found that the direction of the lumbar degenerative spondylolisthesis depended on the level of the apex of lumbar lordosis. Both levels of the vertebra and the apex influenced the vertebral tilt. Furthermore, anterior tilt of the vertebrae is a risk of anterolisthesis, whereas a posterior tilt of the vertebrae is a risk of retrolisthesis.5 Therefore, not only the level of the spondylolisthesis but also the level of the apex may play an important role in determining the direction of the lumbar degenerative spondylolisthesis. The etiologies and mechanisms of lumbar degenerative spondylolisthesis are multifactorial,1, 2, 3 and further investigations are required.
Compliance with ethical standards.
Author contributions
Takaomi Kobayashi: Conceptualization; Formal analysis; Investigation; Methodology; Writing - original draft. Tadatsugu Morimoto: Data curation; Formal analysis; Investigation; Methodology; Project administration; Roles/Writing - original draft.
Funding
None.
Declaration of competing interest
None declared.
Contributor Information
Takaomi Kobayashi, Email: takaomi_920@yahoo.co.jp.
Tadatsugu Morimoto, Email: sakiyuki0830@gmail.com.
References
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