Understanding the Pathophysiology of L5-S1 Loss of Lordosis and Retrolisthesis: An EOS Study of Lumbopelvic Movement Between Standing and Slump Sitting Postures

World Neurosurg. 2022 Feb;158:e654-e661. doi: 10.1016/j.wneu.2021.11.034. Epub 2021 Nov 14.


Objective: To understand the pathophysiology of L5-S1 loss of lordosis and retrolisthesis by comparing 2 commonly assumed physiological weight-bearing postures.

Methods: This 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.

Results: L5-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).

Conclusions: Degenerative 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.

Keywords: Degenerative; Lordosis; Retrolisthesis; Slump sitting; Standing.

MeSH terms

  • Humans
  • Lordosis* / diagnostic imaging
  • Lumbar Vertebrae / diagnostic imaging
  • Posture
  • Prospective Studies
  • Sitting Position
  • Spondylolisthesis* / diagnostic imaging
  • Spondylolisthesis* / epidemiology