Degenerative lumbosacral spondylolisthesis: possible factors which predispose the fifth lumbar vertebra to slip

Factors Predisposing to The Formation of Degenerative Spondylolisthesis-A Narrative Review

The relationship between various factors predisposing to the formation of spondylolisthesis, including degenerative spondylolisthesis, has been analyzed by many authors. However, not all observations are consistent. In this review, we identified factors whose impact on the prevalence of spondylolisthesis was most often mentioned in the literature. These included gender, age, bone mineral density, ethnic origin, and oophorectomy. The results were inclusive in terms of physical activity, pregnancy status, and use of hormone replacement therapy. Associations between diabetes and smoking were very poorly marked. The literature so far has identified a number of factors significantly affecting the incidence of degenerative spondylolisthesis. These include age, gender, body weight, ethnic origin, bone mineral density, and hormonal balance. Radiological parameters, which include iliac crest, pelvic tilt, pelvic incidence, sacral slope, and lumbar lordosis, may also be of great importance for assessing changes in the occurrence and progression. However, the authors do not agree on the real significance of individual factors. The aim of this review was to identify the factors predisposing to the formation of degenerative spondylolisthesis, the importance of which has been suggested in the current literature. The systematization of knowledge in this field can allow a more accurate adjustment of the treatment plan for each patient affected by this condition.

A morphological characterization of the lumbar neural arch in females and males with degenerative spondylolisthesis

Background

Although Degenerative Spondylolisthesis (DS) is a common osseous dysfunction, very few studies have examined the bony morphology of lumbar the neural arch in the population afflicted with DS. Therefore, this study aimed to characterize the neural arch (NA) morphology along the entire lumbar spine in individuals with degenerative spondylolisthesis (DS) and compare them to healthy controls.

Methods

One hundred CTs from a database of 500 lumbar CTs of spondylolisthesis were selected. We excluded vertebral fractures, non-L4-L5 slips, previous surgeries, vertebral spondyloarthropathies, and scoliosis. Scans were divided into a study group of 50 individuals with single-level DS (grades 1–2) at L4–5 (25 males and 25 females), and an age-sex matched control group of 50 individuals. Linear and angular measurements from all lumbar segments included: vertebral canals, intervertebral foramens, pedicles, and articular facets.

Results

Compared with the controls, all individuals with DS had greater pedicle dimensions in the lower lumbar segments (∆ = 1 mm–2.14 mm) and shorter intervertebral foramens in all the lumbar segments (∆range:1.85 mm–3.94 mm). In DS females, the lower lumbar facets were mostly wider (∆ = 1.73–2.86 mm) and more sagittally-oriented (∆10°) than the controls. Greater prevalence of grade-3 facet arthrosis was found only in the DS population (DS = 40–90%,controls = 16.7–66.7%). In DS males, degenerated facets were observed along the entire lumbar spine (L1-S1), whereas, in DS females, the facets were observed mainly in the lower lumbar segments (L4-S1). Individuals with DS have shorter intervertebral foramens and greater pedicle dimensions compared with controls.

Conclusions

Females with DS have wider articular facets, more sagittally-oriented facets, and excessively degenerated facets than the controls. This unique NA shape may further clarify DS’s pathophysiology and explain its greater prevalence in females compared to males.

Pathomechanisms and Predisposing Factors for Degenerative Lumbar Spondylolisthesis: A Narrative Review

The pathomechanism of degenerative lumbar spondylolisthesis (DLS) is not fully understood and is likely to be multifactorial. The primary cause of DLS likely is age-related degeneration of all of the components of the segments and their surroundings. Subsequently, additional factors, such as anatomical, hormonal, and mechanical stress factors, may drive the spinal segments to DLS. Reported predisposing factors that have shown a consistent association with DLS include older age, female sex, sagittal facet joint orientation, and high pelvic incidence. Future prospective epidemiological studies that include large groups of subjects and use multivariate analyses of the possible predisposing factors are needed.

A comparative study of gait characteristics associated with and without degenerative lumbar spondylolisthesis in patients with lumbar spinal stenosis

BACKGROUND

Reported characteristics of DS include forward slippage of the superior lumbar relative to the inferior lumbar, lumbar instability, increased lumbar lordotic angle, and high body mass index (BMI). However, to our knowledge, only static measurements were conducted in previous studies, and no dynamic observations exist. In this crosssectional study, the gait of patients with and without DS in LSS was compared, and their characteristics were examined using a three-dimensional motion analysis system.

METHODS

In total, 42 patients with LSS were included. Lumbar lordosis angle, sacral tilt angle, lumbar slip rate determined from X-ray images, the Zurich Claudication Questionnaire (ZCQ), the visual analog scale (VAS), and BMI were evaluated. U-COM length was the distance between the upper center of mass (COM) and the body's COM, while L-COM length was the distance between the lower COM and the COM. Each DS and Non-DS group evaluation was compared using the Mann-Whitney U-test. Additionally, multivariate analysis was performed using factors with significant differences as explanatory variables and with or without DS as the target variable.

RESULTS

Lumbar lordotic angle was significantly higher in the DS group and there was a significant difference between U-COM and L-COM lengths in the sagittal planes at heel contact (HC) and toe-off (TO). L-COM length at HC and TO was a significant variable when the lumbar lordotic angle was adjusted as a confounding factor in multivariate analysis.

CONCLUSIONS

The U-COM and L-COM lengths in the DS group were both extended and the line connecting each COM was inclined backward on the sagittal plane at HC and TO during gait. Our study showed that L-COM length was associated with or without DS.

Correlation between the sagittal spinopelvic alignment and degenerative lumbar spondylolisthesis: a retrospective study

Background

Pain and disability associated with degenerative lumbar spondylolisthesis (DLS) results in significant burden on both the patients’ quality of life and healthcare costs. Currently, there is controversy regarding the specificity of spinopelvic measures of sagittal plane alignment with respect to DLS. Moreover, the correlation among spinopelvic parameters of sagittal plane alignment remains to be clarified. Our aim in this study was to compare these measurements between patients with single-segment DLS at L5 and a control group with no history of DLS.

Methods

Our study group was formed of 132 patients who underwent full length lateral view radiographs of the spine in a relaxed standing posture. Among these, DLS at L5 was identified in 72 patients, forming the DLS group, with no radiographic evidence of lumbar spine disease in the remaining 60 patients, forming the control group. The patient and control groups were balanced with regard to age and sex distribution. The following spinopelvic parameters of sagittal plane alignment were measured: angle of incidence (PI) and tilt (PT) of the pelvis; sacral slope (SS); thoracic kyphosis (TK); lumbar lordosis (LL); and the spinal sagittal vertical axis (SVA). The Meyerding grade of L5 slippage was quantified for each patient in the DLS group.

Results

Measures of TK, PI, SS, and LL were significantly greater in the DLS than control group (P <  0.05), with no between-group difference in SVA and PT. In the DLS group, the grade of L5 slippage correlated with SS (r = 0.873, P <  0.0001), PI (r = 0.791, P <  0.0001) and LL (r = 0.790, P <  0.0001). Moreover, the measurement for SS correlated more strongly with the PI (r = 0.94, P <  0.01) than the LL (r = 0.69, P <  0.01).

Conclusion

Measurements of SS, PI, and LL were specifically associated with DLS, with measurements correlating positively with the grade of slippage.

Electronic supplementary material

The online version of this article (10.1186/s12891-018-2073-z) contains supplementary material, which is available to authorized users.

Radiographic Analysis of the Lumbosacral Juncture: Is There a Critical Sacral Angle for Total Disc Replacement?

Study Design

Retrospective review of a patient cohort through a prospective study.

Purpose

To determine whether there are correlations between radiographic measurements, including sacral slope (SS) and pelvic incidence (PI), and self-reported clinical outcomes among single-level L5/S1 ProDisc-L patients.

Overview of Literature

The lumbosacral juncture presents unique biomechanical challenges with respect to artificial disc replacement (ADR) because of its orientation and consequential shear loading. Reports of inferior outcomes at L5/S1 compared to those of the outcomes at the levels above, including increased facet joint pain, suggest a relationship with the sacral inclination at L5/S1.

Methods

Plain standing lateral radiographs of 71 patients (age, 26–65 years) who underwent ADR at L5/S1 for degenerative disc disease were reviewed. SS and PI were measured based on pretreatment and initial follow-up standing films. Patient's average adjusted self assessments included the Oswestry disability index and visual analog scale for pain 2 years after ADR. Correlation coefficients were computed to evaluate relationships between radiographic parameters and clinical outcomes. Analysis of covariance was used to evaluate multivariate relationships among factors, including radiographic parameters, body mass index (BMI), and clinical outcomes.

Results

SS and PI values were obtained from 71 patients. The average SS was 33.3° and average PI was 39.9°. At the 24-month follow-up, no significant correlations (p≥0.05) were observed between radiographic parameters and clinical outcomes. BMI, age, and sex did not explain any variability in the relationships between clinical outcomes and SS and PI.

Conclusions

We reviewed a large range of SS angles and found no associations between SS, PI, or BMI and clinical outcomes after ADR at L5/S1. These preliminary results demonstrate that ADR provided maintainence of pain relief and functional improvement for a wide range of SS angles, suggesting that steeper angles are not a contraindication for ADR.

Lumbar degenerative spondylolisthesis epidemiology: A systematic review with a focus on gender-specific and age-specific prevalence

The epidemiology of lumbar degenerative spondylolisthesis (DS) remains controversial. We performed a systematic review with the aim of gaining a better understanding of the prevalence of DS in the general population. The results showed that the prevalence of DS is very gender- and age-specific. Few women and men develop DS before they are 50 years old. After 50 years of age, both women and men begin to develop DS, with women having a faster rate of development than men. For elderly Chinese (≥ 65 years, mean age: 72.5 years), large population-based studies MsOS (Hong Kong, females: n = 2000) and MrOS (Hong Kong, males: n = 2000) showed DS prevalence was 25.0% in women and 19.1% in men. The female:male (F:M) prevalence ratio was 1.3:1. The published data for MsOS (USA) and MrOS (USA) studies seem to show that elderly Caucasian Americans have a higher DS prevalence, being approximately 60-70% higher than elderly Chinese; however, the F:M prevalence ratio was similar to the elderly Chinese population. Patient data showed that female patients more often received surgical treatment than male and preliminary data showed the ratio of female to male patients receiving surgical treatment did not differ between Northeast Asians (Chinese, Japanese, and Korean), Europeans, and American Caucasians, being around 2:1 in the elderly population. The existing data also suggest that menopause may be a contributing factor for the accelerated development of DS in postmenopausal women. The translational potential of this article: A better understanding of epidemiology of lumbar degenerative spondylolisthesis can support patient consultation and treatment planning.

The Relationship Between Osteoarthritis of the Lumbar Facet Joints and Lumbosacropelvic Morphology

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

To investigate the relation between lumbosacropelvic morphology and the presence and degree of facet joint degeneration.

SUMMARY OF BACKGROUND DATA

Osteoarthritis of the facet joints is one of the most common degenerative changes in the spine. It is considered to be formed secondary to repetitive stress or trauma and spinal deformity with secondary overload. The cause(s) of facet joints osteoarthritis, however, have not been clearly identified.

METHODS

Abdominal computed tomography (CT) images of 723 patients which were taken between the years 2010 and 2014 were evaluated retrospectively. Patients with prior lumbar spinal surgery, serious congenital anomalies on CT, incomplete or complete lumbosacral transition, severe scoliosis, were excluded from the study. To eliminate the age- and sex-related differences in spinopelvic morphology, a study group was formed of the remaining subjects by including patients from a specific age group (30-35 yr) and same sex (females). For each patient the presence and grade of facet joint degeneration was investigated. In addition, pelvic incidence (PI), sacral slope and the angles of L1-L5 lumbar lordosis, sacral table, L5 vertebra posterior, and sacral kyphosis were measured for each patient.

RESULTS

Sacral slope, sacral kyphosis, and L1-L5 lumbar lordosis angle were significantly higher in patients with osteoarthritic compared with normal subjects (P = 0.015, P = 0.018, P = 0.016). L5 vertebra posterior and sacral table angle were found to be significantly lower in patients with osteoarthritic than in normal subjects (P = 0.019, P = 0.007). The degree of facet joint degeneration was noticed to increase parallel to the decrease in the sacral table angle and L5 vertebra posterior angle, and to the increase in the L1-L5 lumbar lordosis, PI, and sacral slope.

CONCLUSION

A close relation exists between the presence and degree of degeneration in the facet joint and lumbosacral pelvic morphology. Prevalence and degree of the degeneration in facet joint increases as the angle of sacral slope, L1-L5 lumbar lordosis, and PI increases or the angle of sacral table and L5 vertebra posterior decreases.

LEVEL OF EVIDENCE

4.

Risk factors for degenerative spondylolisthesis: a systematic review

STUDY DESIGN

 Systematic literature review.

RATIONALE

 Many authors have postulated on various risk factors associated with the pathogenesis of degenerative spondylolisthesis (DS), yet controversies regarding those risk factors still exist.

OBJECTIVE

 To critically appraise and summarize evidence on risk factors for DS.

METHODS

 Articles published before October 15, 2011, were systematically reviewed using PubMed and bibliographies of key articles. Each article was subject to quality rating and was analyzed by two independent reviewers.

RESULTS

 From 382 citations, 30 underwent full-text review. Fourteen studies met inclusion criteria. All but two were considered poor quality. Female gender and higher facet joint angle were consistently associated with an increased risk of DS across multiple studies. Multiple studies also consistently reported no association between back pain and prolonged occupational sitting. Associations between age, parity, lumbosacral angle, lumbar lordosis, facet joint tropism, and pelvic inclination angles were inconsistent.

CONCLUSIONS

 There appears to be consistent evidence to suggest that the risk of DS increases with increasing age and is greater for females and people with a greater facet joint angle.

The incidence of spondylolysis and spondylolisthesis in children with osteogenesis imperfecta

BACKGROUND

Spondylolysis and spondylolisthesis are common abnormalities of the lumbar spine. The incidence of these diagnoses is recognized in the healthy population. However, their incidence in osteogenesis imperfecta (OI) patients is less well defined.

METHODS

This is a retrospective radiographic review of patients treated in the OI clinic from a single institution. Lateral radiographs were reviewed on all available patients to assess the incidence of spondylolysis and spondylolisthesis in this patient population. The morphology of the pedicle and pars interarticularis was also evaluated to identify any abnormalities or dysplasia of these structures.

RESULTS

One hundred ten of the 139 patients treated in the OI clinic met the inclusion criteria for this study. Of these patients, 79% (87 of 110) were ambulatory. The overall incidence of spondylolysis in this pediatric OI population was found to be 8.2% (9 of 110) at an average age of 7.5 years. The incidence of spondylolisthesis was 10.9% (12 of 110) at an average age of 6.5 years with 75% (3 of 12) being isthmic type and 25% (3 of 12) dysplastic. The combined incidence of spondylolysis and spondylolisthesis was 19.2%. Incidentally, the pedicle length was noted to be elongated in 40.0% (44 of 110) of this OI population.

CONCLUSIONS

This study found that the incidence of spondylolysis in a group of children with OI was much higher than in the normal pediatric population, which has been reported to be 2.6% to 4.0%. This incidence was also found to be higher than previously reported incidence of spondylolysis in OI patients (5.3%). The incidence of spondylolisthesis was also found to be much higher than that of the normal pediatric population (4.2%). It is important to recognize this higher incidence of these abnormalities and to anticipate future associated symptoms and potential worsening listhesis that can clinically affect the lifestyles of these children and potentially require surgical treatment. The clinical significance of these findings will necessitate long-term follow-up.

Two- and three-dimensional reformatted computed tomography imaging analysis of the lumbosacropelvic structure in degenerative anterolisthesis

AIM

To evaluate the differences in the lumbosacropelvic structure between normal individuals and those with pseudospondylolisthesis.

MATERIALS AND METHODS

The renal stone protocol abdominal CT images of 452 patients were retrospectively analysed. Twenty individuals who had degenerative anterolisthesis at the L5-S1 level were included in the study. Moreover, a control group of individuals was formed, similar in age and gender to the study group. A number of linear and angular lumbosacral morphological parameters were evaluated using two- and three-dimensionally reformatted CT images. The data of the two groups were compared using the t-test and Mann-Whitney U-test.

RESULTS

There was an association between spondylolisthesis and decreased thickness of the transverse process (p=0.01), the height of the iliac crest (p=0.028), lumbar angle (p=0.041), sacral table angle (p=0.033), sacral table index (p=0.0001), sacral kyphosis (p=0.025), sacral slope (p=0.007), and width of the transverse process (p=0.038), and increased transverse articular dimension of the facet joint (p=0.003), axial angle of the facet joint (p=0.002), sagittal angle of the facet joint (p=0.012), S1 vertebra interfacet index (p=0.003), the distance between the L5 vertebral transverse process and the iliac crest (p=0.003), pelvic incidence (p=0.016), L5 vertebra posterior angle (p=0.001), and intersacroiliac joint angle (p=0.024).

CONCLUSION

The lumbosacropelvic morphology in patients with degenerative spondylolisthesis is quite different from that of normal individuals. These abnormalities should be revealed using imaging methods as they can be defining for pseudospondylolisthesis development and have important effects on therapy planning.

Clinical application of a novel assessment for lumbosacral stability

OBJECT

To evaluate the grade of lumbosacral stability, shape analysis was conducted on plain radiographs of the lumbar spine.

METHODS

One hundred twenty-six patients were classified into 2 groups: those with a single-segment disc space narrowing at L5-S1 or at L4-5. Stability was evaluated using the discriminant function (z score) derived from the analysis of radiographic parameters-that is, relative thickness of transverse process of L-5 and the sacral table angle.

RESULTS

In patients with a space narrowing at L5-S1, the author observed a significantly slender L-5 transverse process and acute obliquity of the sacral endplate; accordingly, the z score was negative. In patients with a broad transverse process and a positive z score, the segment associated with disc height loss was L4-5. Thus, a close correlation was found between the site of the disc height loss and the bony characteristics of L-5 and S-1. Furthermore, it could be expected with a high degree reliability that when young adult patients had a z score less than -2 or -3, their L-5 vertebra would develop degenerative spondylolisthesis after middle age and the L5-S1 segment could be saved from age-related alterations as long as the z score was greater than 2.5. The constitutional characteristics of the lumbosacral junction may exert a major influence on the site of disc degeneration.

CONCLUSIONS

Stability at the lumbosacral junction was thought to be quantitatively represented by the z score, with z being designated the lumbosacral stability score.

Radiographic analysis of newly developed degenerative spondylolisthesis in a mean twelve-year prospective study

STUDY DESIGN

Prospective study of community-based female volunteers.

OBJECTIVE

To investigate the incidence of newly developed degenerative spondylolisthesis (DS) among those without baseline deformity, and to clarify radiographic characteristics and predictors of DS.

SUMMARY OF BACKGROUND DATA

There has been limited number of prospective studies of DS. Our on-going cohort study of healthy volunteers enabled long-term observation of highly susceptible perimenopause female subjects.

METHODS

A final total of 142 female subjects without spondylolisthesis at baseline radiographs were included and followed up for more than 8 years. Standardized serial entire spine radiographs were used to measure spinopelvic alignment, including pelvic incidence (PI), vertebral inclination angle, disc height, vertebral size, and facet orientation.

RESULTS

The incidence of newly developed DS was 12.7%. Comparison between DS and non-DS subjects demonstrated that DS subjects had significantly greater baseline lumbar lordosis, PI, vertebral inclination angle, and smaller vertebral size. Exaggerated lumbopelvic alignment was more prominent in L3-DS than in L4-DS, and L4-DS was associated with the decrease in L4/5 disc height. Multivariate analysis revealed that PI, L4 vertebral inclination, adjusted vertebral size, and facet sagittalization were independent predictors of the development of DS.

CONCLUSION

This was the first study to confirm the relationship of PI and the development of DS in a long-term prospective observation. Proposed pathogenetic differences might explain the fact that L4-DS is far more prevalent than L3-DS. The development of DS could be predicted by baseline lumbopelvic morphology among the highly susceptible perimenopause women.

Prevalence of sacral spina bifida occulta and its relationship to age, sex, race, and the sacral table angle: an anatomic, osteologic study of three thousand one hundred specimens

STUDY DESIGN

An anatomic, osteologic study of spina bifida occulta (SBO).

OBJECTIVE

To determine the prevalence and patterns of SBO in a large population and examine its relationship to age, sex, and race; then to evaluate SBOs relationship to the sacral table angle (STA) when compared with an age-matched control group.

SUMMARY OF BACKGROUND DATA

SBO has a reported prevalence of 1.2% to 50% and has been implicated in various pathologic problems. SBO is often associated with spondylolysis or spondylolithesis. The STA has been implicated as an etiologic or predictive factor in the presence of pars defects.

METHODS

Three thousand one hundred osteologic specimens were evaluated for the presence of SBO. SBO was graded on a scale from 0 to III. Information on the age, sex, race, and STA of each specimen was recorded and measured, respectively. Prevalence and patterns of SBO were enumerated. The STAs of an age-matched control group of 355 specimens were examined. The SBO group and control groups were compared in regards to STA, controlling for age, sex, and race.

RESULTS

Overall, 355 specimens displayed SBO, for an overall prevalence of 12.4%. Of the SBO specimens, 68.7% were white, 88.2% were men, 53% were grade I, 37% II, and 10% III. All 3 grades of SBO were more common in men than women (88.2% vs. 11.8%) and more prevalent in whites than blacks (68.7% vs. 31.3%) (P = 0.01). SBO decreased in prevalence with increasing age. The average STA in SBO specimens was 95.9 degrees . This differed from an age-matched control group, 92.1 degrees (P < 0.0001). Every 1 degrees increase in STA resulted in a 6% increased likelihood of SBO. In SBO specimens, the STA decreased with increasing age, contrary to age-matched controls.

CONCLUSION

SBO has an overall prevalence of 12.4% in a large, diverse population. SBO is more common in men and whites and decreases in prevalence with increasing age. The STA is greater in SBO when compared with controls and an increased STA predicts SBO. In SBO, the STA decreases with increasing age.