Level-Specific Differences in Degenerative Spondylolisthesis: A Comparative Analysis of L3 versus L4 Spinopelvic Alignment, Facet Joint Morphology, and Muscle Degeneration Patterns

Xinghua Zhou; Jianhua Ren; Junkai Kou; Hengrui Chang; Di Zhang; Xianzhong Meng

doi:10.1016/j.wneu.2025.124629

Level-Specific Differences in Degenerative Spondylolisthesis: A Comparative Analysis of L3 versus L4 Spinopelvic Alignment, Facet Joint Morphology, and Muscle Degeneration Patterns

World Neurosurg. 2025 Nov 7:205:124629. doi: 10.1016/j.wneu.2025.124629. Online ahead of print.

Authors

Xinghua Zhou¹, Jianhua Ren¹, Junkai Kou¹, Hengrui Chang¹, Di Zhang¹, Xianzhong Meng²

Affiliations

¹ Department of Spine Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, China.
² Department of Spine Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, China. Electronic address: 36700973@hebmu.edu.cn.

PMID: 41205863
DOI: 10.1016/j.wneu.2025.124629

Abstract

Objective: To investigate the distinct biomechanical characteristics of L3 versus L4 degenerative spondylolisthesis (DS) by comparing spinopelvic sagittal parameters, facet joint morphology, and paraspinal muscle degeneration patterns.

Methods: This retrospective comparative cohort study included 112 patients who underwent surgical treatment for single-level DS (48 L3-L4, 64 L4-L5) between 2021 and 2023. Comprehensive radiographic analysis assessed spinopelvic sagittal alignment parameters using full-spine standing radiographs. Facet joint angles and pedicle-facet angles were measured using computed tomography. Paraspinal muscle cross-sectional area and fat infiltration were quantified using magnetic resonance imaging at multiple lumbar levels.

Results: L4DS patients demonstrated significantly greater global sagittal imbalance compared to L3DS patients (sagittal vertical axis: 3.43 ± 3.99 mm vs. 0.13 ± 3.86 mm, P < 0.01). L3DS patients exhibited larger facet joint angles at L4-L5 and L5-S1 levels, suggesting protective compensatory adaptations. L4DS patients showed more severe vertebral slippage (19.02 ± 7.47% vs. 15.85 ± 7.09%, P < 0.05) and greater multifidus fat infiltration at the L3-L4 level (40.36 ± 14.06% vs. 30.42 ± 13.31%, P < 0.05). Muscle cross-sectional areas remained comparable between groups.

Conclusions: L3 and L4 DS represent distinct pathological entities with fundamentally different compensatory mechanisms, morphological adaptations, and degenerative patterns. These level-specific differences may have important implications for surgical planning and treatment strategies.

Keywords: Degenerative spondylolisthesis; Facet joint morphology; Lumbar spine biomechanics; Paraspinal muscle degeneration; Sagittal balance; Spinopelvic alignment.