• HeyHwee Weng DennisHWDDepartment of Orthopaedic Surgery, National University Hospital, Singapore. Electronic address: doshhwd@nus.edu.sg., LimJustin Chia LoongJCLDepartment of Orthopaedic Surgery, National University Hospital, Singapore., Gin Way Law, Gabriel Ka-Po Liu, and Hee-Kit Wong.
• Department of Orthopaedic Surgery, National University Hospital, Singapore. Electronic address: doshhwd@nus.edu.sg.
• World Neurosurg. 2022 Feb 1; 158: e654-e661.

ObjectiveTo understand the pathophysiology of L5-S1 loss of lordosis and retrolisthesis by comparing 2 commonly assumed physiological weight-bearing postures.MethodsThis was a prospective comparative study of whole-body standing and slump sitting EOS radiographs in clinic patients presenting with back pain or lower limb radicular pain. Patients with prior spinal intervention, malignancy, trauma, inflammatory diseases, transitional lumbosacral vertebra, pregnancy, and L5-S1 retrolisthesis or spondylolisthesis from nondegenerative causes were excluded. C7 sagittal vertical axis, global cervical angle, global thoracic angle, global lumbar angle, thoracolumbar angle, T1-slope, pelvic incidence, pelvic tilt, sacral slope, L5-S1 angle, L5-S1 vertebral translation, L5-S1 disc height, and presence of L4-5 vertebral translation were measured. Univariate and multivariate analyses were performed to identify predictors of L5-S1 lordosis loss and retrolisthesis.ResultsL5-S1 loss of lumbar lordosis (7.02 ± 9.90°, P < 0.001), retrolisthesis (0.07 ± 0.411 cm, P < 0.001), and loss of disc height (0.10 ± 0.23 cm, P < 0.001) occurred when changing from standing to slump sitting along with other sagittal profile changes (P < 0.001). Taller L5-S1 disc height (odds ratio [OR] 2.57, P = 0.04), larger lumbar range-of-motion change (OR 3.82, P = 0.012), lower sacral slope on sitting (OR 2.50, P = 0.043), and presence of L4-5 spondylolisthesis (OR 2.75, P = 0.032) were predictive of larger L5-S1 lordosis loss (>7°) on multivariate analysis, while larger lumbar range-of-motion change (OR 2.21, P = 0.050) and presence of L4-5 spondylolisthesis (OR 3.08, P = 0.023) were predictive of greater L5-S1 retrolisthesis (>0.07 cm).ConclusionsDegenerative L5-S1 loss of lordosis and retrolisthesis likely result from long-standing lower lumbar spine bending forces against the posterior ligamentous complex with slump sitting, predisposed by a negatively sloped sacrum and increased lumbar flexibility.Copyright © 2021 Elsevier Inc. All rights reserved.

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