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The Impact of Lumbar Laterolisthesis on Degenerative Lumbar Surgery
Lumbar laterolisthesis (or lateral spondylolisthesis) is the lateral displacement of one vertebra relative to the vertebra below it, commonly resulting from degenerative changes. An estimated 10% of patients exhibit radiographic evidence of laterolisthesis.1 The prevalence of laterolisthesis is highly influenced by factors such as age, sex, and the presence of other degenerative spinal conditions. For instance, it is significantly more common in women, and its prevalence increases gradually with age.1 It often presents as a triaxial defect due to the combination of axial rotation and anterior translation. 2 Laterolisthesis is significantly more common in individuals with scoliosis, occurring in 13% to 20% of adults with scoliosis.1–4 Its multidimensional and multifactorial pathophysiology can present with variable symptomology and poses greater variability in surgical management compared to anterolisthesis, increasing the complexity of diagnosis and management.5
Despite its clinical relevance, degenerative lumbar laterolisthesis remains an underrepresented topic in literature. Its role in degenerative spinal pathology is substantial, yet it is not widely recognized as a major contributor to spinal instability and surgical complexity. Greater focus is needed in research and clinical practice, as it complicates degenerative lumbar surgery and can impact patient outcomes. Therefore, this article reviews the current evidence on the clinical impact of lumbar laterolisthesis on degenerative lumbar surgery.
Pathophysiology of Lumbar Laterolisthesis
Biomechanical and Structural Contributors
Lumbar laterolisthesis results from a complex interplay of biomechanical and structural changes in the spine that lead to segmental instability and progressive spinal misalignment, 6 causing biomechanical pathology in the spine. A key biomechanical factor is disc degeneration, which results in the loss of disc height and disrupts the normal load-bearing capacity of the spinal column.7 Loss of disc height permits increased segmental motion, allowing lateral translation of vertebral segments. 8 Asymmetrical disc degeneration further exacerbates instability, as one side of the vertebra experiences greater collapse, promoting lateral displacement.6 Facet joint degeneration also plays a role in laterolisthesis.9 Normally, the facet joints guide and restrict spinal movement, resisting excessive shearing forces.9 However, the occurrence of asymmetric facet joint arthropathy reduces resistance to lateral translation, allowing for progressive displacement.9 Additionally, ligamentous laxity contributes to spinal instability.10 The intertransverse ligaments, which limit lateral bending, and the interspinous ligaments, which help stabilize the posterior column, progressively weaken due to chronic stress and degeneration. This laxity allows increased motion at the affected segment, especially when combined with asymmetric disc and facet degeneration.10
The interplay of these factors was further demonstrated in a seminal biomechanical study by Okushima et al, who conducted an in vitro study on whole lumbar cadaveric spines under multidirectional loading.11 Their results demonstrated that force applied in the anterolateral direction produced greater lateral translation than force in the posterolateral direction, suggesting that specific vectors of load may disproportionately destabilize the lumbar spine. Moreover, they found that the removal of the facet joints at L4-L5 resulted in significantly more lateral translation than the removal of the intervertebral discs under shear loading conditions, highlighting the critical role of facet joints in resisting translational instability. These findings provide key insights into the pathogenesis of laterolisthesis, emphasizing that while disc degeneration facilitates abnormal motion, progressive facet joint degeneration plays a primary role in destabilizing the spine and allowing for pathological lateral vertebral translation, particularly at vulnerable lumbar segments.
Association With Spinal Malalignment
The biomechanics of lateral vertebral translation may be highly interlinked with the pathophysiology of scoliosis, though the causative relationship remains speculative.4 Asymmetric degeneration in intervertebral discs and facet joints predisposes the spine to lateral vertebral translation and excessive curvature of the spine while the resulting coronal malalignment further accelerates degenerative changes.4
Toyone et al described a correlation between vertebral translation and rotation, demonstrating that in patients with both laterolisthesis and scoliosis, cephalad vertebrae rotated toward the convex side of the primary scoliotic curve while caudal vertebrae rotated toward the convex side of the lumbosacral hemi-curve.4 These findings reinforce the 3-dimensional complexity of laterolisthesis. Additionally, Kilshaw et al found that laterolisthesis was significantly more prevalent in patients with scoliosis (44.0% vs 3.8%), suggesting a strong association between these conditions.1 A retrospective study by Chin et al examined the natural history of degenerative lumbar curves and found that 46% of patients with degenerative scoliosis had laterolisthesis greater than 5 mm at L3- L4, with nonlinear progression occurring most rapidly in women older than 69 years with levoscoliosis.12 This finding underscores that laterolisthesis may not be merely a secondary consequence of degeneration but a primary driver of spinal deformity.
Increasing vertebral translation over time disrupts coronal and sagittal balance, leading to worsening asymmetric loading on the intervertebral discs and facet joint. Marty-Poumarat et al categorized degenerative scoliosis progression into 2 types: Type A, where a pre-existing adolescent scoliosis worsens after skeletal maturity, and Type B, which develops de novo in adulthood, often in association with rotatory subluxation and laterolisthesis.13 Type B scoliosis was found to progress more rapidly, particularly around menopause.13
Development of Spinal Stenosis and Nerve Compression
Laterolisthesis causes anatomical stenosis in a distinctively different way than anterolisthesis. Unlike anterolisthesis, which reduces central canal space through anterior vertebral slippage, laterolisthesis often leads to asymmetrical canal narrowing and foraminal stenosis, producing a unique pattern of neural compression.14 Nerve root stretch injury has been implicated in laterolisthesis-related radiculopathy. Kitab et al systematically reviewed the literature on stretch-related nerve injury, proposing that the dynamic nature of laterolisthesis may result in prolonged or episodic tensile forces on nerve roots, which in turn contribute to radiculopathy.15 The study highlighted that a functional spinal unit experiencing vertebral slippage can create stretch-induced nerve root injuries independent of direct compression. Theyproposed that stretch-induced injury may contribute to chronic pain syndromes, even in the absence of severe foraminal stenosis.
The pattern of neural compression depends on the nature of vertebral slippage. Liu et al found that in degenerative scoliosis with laterolisthesis, L3 and L4 nerve roots were predominantly compressed at the concave side due to foraminal stenosis, while L5 and S1 nerve roots were affected by lateral recess stenosis on the convex side.16 Gardener et al classified stenosis patterns into “open” and “closed” subluxations, with open subluxations (common at L3-L4) causing contralateral lateral recess and foraminal stenosis, while closed subluxations (L1-L2) resulted in ipsilateral stenosis.17
Clinical Presentation
While the clinical presentation of laterolisthesis includes a combination of mechanical and neurological symptoms, lower back pain is the most frequent complaint.18,19 Additionally, many patients also experience lower limb radicular symptoms corresponding to the anatomical compression of nerve roots. 20 This suggests that vertebral rotation and lateral translation at specific lumbar levels disproportionately contribute to radicular symptoms. As laterolisthesis often coexists with degenerative scoliosis, patients frequently experience postural and mechanical impairments. Coronal plane instability has been correlated to compensatory muscle mechanisms, antalgic gait patterns, and limited lumbar range of motion.19,21 Given the complexity of laterolisthesis’ etiology and presentation, integrating imaging studies is essential for correlating patients’ clinical signs and symptoms with the underlying structural pathology in laterolisthesis.
Radiographic Investigations
There is a range of different imaging modalities that are essential in the investigation and management of lumbar laterolisthesis. Radiographs remain the gold standard for assessing spinal alignment, with lateral and anteroposterior films offering critical insight into overall spine positioning. 22 When evaluating lateral translation on x-ray images, measurements such as segmental lateral translation and coronal wedge angle are useful for assessing single-level laterolisthesis. 23,24 The coronal sacral vertical line (CSVL) reflects global coronal alignment and horizontal displacement. Together, these metrics aid in assessing progression and evaluating postural malalignment.
Lateral radiographs are also useful for detecting facet locking, facet joint subluxation, and sagittal malalignment, which may develop because of compensatory postural adaptations. Therefore, it is essential to recognize laterolisthesis as a tri-axial deformity and to assess all relevant parameters across the necessary planes for a comprehensive analysis. In the sagittal plane, key parameters such as the sagittal vertical axis (SVA), L1-S1 lordosis, pelvic incidence (PI), and pelvic tilt (PT) offer valuable insight into changes in global spinal alignment.25
Dynamic radiograph assessments, including flexion-extension and lateral bending views, offer valuable insight into spinal mechanics under different loads. Flexion-extension films help detect sagittal instability by revealing excessive vertebral motion in the sagittal plane, while lateral bending views assess coronal instability and curve flexibility.26,27 These imaging modalities are important in evaluating laterolisthesis, as lateral instability has been associated with worse preoperative pain, higher ODI scores, and greater limitations in activities of daily living.27
Computed tomography (CT) is a highly valuable imaging modality for evaluating lumbar laterolisthesis. CT provides precise evaluation of bony degenerative changes and 3-dimensional changes seen in laterolisthesis. 28–30 The high-resolution imaging of the bone offers comprehensive visualization of spinal anatomy, enhancing preoperative planning and surgical decision-making. Hounsfield unit (HU) values on CT have been utilized to assess bone health, serving as a prognostic factor in various aspects of spine surgery, such as pedicle screw loosening or cage subsidence in surgery. 31 These findings are crucial for preoperative planning in laterolisthesis, as they guide the approach, assess mechanical instability and compressive pathology, and determine the extent of decompression or correction necessary.
Magnetic resonance imaging (MRI) is another key modality in evaluating lumbar laterolisthesis. It provides precise visualization of central canal stenosis, lateral recess stenosis, and foraminal stenosis, aiding in identifying associated nerve impingement in laterolisthesis, which can result in combined stenotic pathology even at a single level. 32 Its ability to localize stenosis and clarify its primary source, whether due to disc herniation, ligamentum flavum hypertrophy, or facet arthropathy, is essential for accurate diagnosis and surgical planning. All of these imaging modalities not only guide clinical management but also underscore the need for standardized classification systems that capture the complexity of degenerative laterolisthesis.
Classifications of Laterolisthesis
Laterolisthesis classification parallels other spondylolisthesis classifications but is more complex due to its frequent multiplanar involvement. Unlike anterolisthesis, which has well-established classification systems, laterolisthesis lacks a widely accepted framework, though several methods have been proposed. For example, Ploumis et al categorized lumbar laterolisthesis severity by measuring both lateral translation displacement and intervertebral rotation using the Nash-Moe grading scale. Their classifications included Grade I (≤5 mm), Nash-Moe 0-1; Grade II (6–10 mm), Nash-Moe 0-1; and Grade III (>11mm), Nash-Moe 1-2. 2 In addition to measuring lateral translation, lumbar laterolisthesis has also been classified based on the anatomic changes to the intervertebral discs, which are affected by subluxation and translation.
Laterolisthesis can be radiographically classified based on 2 key aspects: coronal plane morphology and axial rotation. Guillaumat et al have classified lateral subluxations in the context of degenerative scoliosis into 3 categories—open, closed, and parallel subluxations—according to differing mechanisms and mechanical properties. 33 Open subluxations widen the disc space due to vertebral rotation; closed subluxations narrow it due to facet erosion, and parallel subluxations involve only translation, occurring without disc wedging, rotation, or facet erosion. In terms of axial rotation, several grading systems exist to quantify vertebral rotation, including Cobb, Nash-Moe, and Peridolle methods. 34 Each method serves different insights into the severity and nature of listhesis. The Cobb method divides the vertebral body into 6 sections; the region aligned with the spinous process determines its grading. 34 The Nash-Moe grading scale measures the percentage of convex pedicle displacement relative to vertebral width, a key factor in assessing the degenerative progression of laterolisthesis. 34,35
These classification systems are particularly useful for assessing rotational deformity and coronal plane malalignment, which are key features of degenerative lumbar laterolisthesis. Accurately classifying these abnormalities helps determine instability severity and guide surgical decision-making. While these systems help characterize degenerative patterns in laterolisthesis, their prognostic value remains unclear. Furthermore, no universally accepted classification exists for single-level lumbar degenerative laterolisthesis, highlighting the need for further research into classification systems that stratify laterolisthesis according to clinical outcomes.
Surgical Management
Decision-Making
Surgical intervention for lumbar laterolisthesis is generally indicated in patients experiencing progressive neurological deficits, severe mechanical back pain, or neurogenic claudication that does not respond to conservative treatment. 36 Clinical and radiographic indications for surgery typically include worsening radiculopathy or neurogenic claudication, instability exceeding 3 mm on dynamic imaging, significant foraminal or central stenosis, and progressive coronal imbalance. 37–41 While limited studies focus exclusively on lumbar laterolisthesis, research on degenerative lumbar spondylolisthesis (DLS) suggests that the presence of segmental instability and symptomatic stenosis are primary determinants in the decision to operate.42,43
The decision between decompression alone and decompression with fusion depends largely on the degree of instability and facet degeneration. Patients with mild lateral translation and well-preserved facet joints may achieve satisfactory outcomes with decompression alone. Studies on DLS indicate that in carefully selected cases, decompression alone provides similar functional improvement compared to fusion over time. 44 However, when lateral translation exceeds 3 mm, there is significant facet joint arthropathy, or the patient exhibits global coronal imbalance, fusion is generally recommended to prevent further instability.
The choice between minimally invasive surgery (MIS) and open surgical approaches depends on the extent of the deformity and the patient’s overall condition. MIS techniques, such as minimally invasive decompression or lateral lumbar interbody fusion (LLIF), have demonstrated advantages in reducing perioperative morbidity, blood loss, and hospital stays while providing similar long-term outcomes to open surgery in appropriately selected patients.45 However, open fusion surgery remains the preferred approach in cases of severe laterolisthesis with coronal imbalance, where extensive alignment correction is required. Decompression alone may be a viable option in cases with minimal lateral translation and stable facet joints. However, fusion should be considered in patients with significant instability or coronal imbalance, as studies suggest that fusion provides superior functional and pain outcomes in moderate coronal deformity (Cobb angle >20°) and that decompression alone has a lower chance of achieving clinical improvement.46,47 Further studies are needed to establish clear surgical guidelines specific to lumbar laterolisthesis and to evaluate long-term outcomes for different surgical strategies.
Surgical Technique and Approach
When fusion is considered, several surgical approaches are available depending on the degree of instability, deformity progression, and associated pathology. Posterior lumbar fusion is a commonly employed fusion approach, as it provides robust stabilization and prevents progression.48 However, transforaminal lumbar interbody fusion (TLIF) or LLIF may be preferable in cases where laterolisthesis is frequently associated with disc collapse and foraminal stenosis. These techniques can restore disc height, provide indirect decompression, and address the coronal asymmetry seen in laterolisthesis, each with its unique advantages.
TLIF, a posterior approach involving facetectomy and partial laminectomy, provides direct and indirect decompression of the neuroforamina.49,50 Moreover, the insertion of an asymmetric interbody cage restores disc height and provides indirect decompression.49,50 Additionally, exposure of the posterior column may allow manual reduction of severe cases of lateral subluxation.51 Pan et al found that DLS patients with local coronal imbalance (lateral translation >5 mm or disc wedging angle >5°) achieved satisfactory sagittal and coronal correction after TLIF, with postoperative functional and pain outcomes comparable to those without imbalance, despite having greater baseline malalignment and worse preoperative function and pain.52 LLIF uses a larger and wider cage compared to TLIF, which may enable more robust restoration of disc height, ligamentotaxis, and indirect foraminal decompression, all of which are key pathomechanical contributors in laterolisthesis.53–55 Additionally, it may provide reliable correction of coronal malalignment while minimizing disruption to the posterior elements.54 Both approaches will likely require posterior instrumentation with pedicle screws to prevent segment motion and cage migration during the fusion process.53,54 Ultimately, the choice of surgical approach should depend on patient-specific factors, including clinical presentation, radiographic findings, and the extent of instability or deformity.
While high-quality evidence specific to laterolisthesis is limited, existing literature on DLS suggests that the aforementioned fusion techniques are effective in reducing slippage and improving postoperative outcomes. 50,52,56–59
Surgical Outcomes Related to Laterolisthesis
Surgical outcomes in lumbar laterolisthesis are influenced by its 3-dimensional complexity, which complicates decompression, fixation, and realignment. Unlike anterolisthesis, its asymmetrical and multiplanar nature may impact surgical outcomes such as reoperation rates, pain relief, and functional improvement.
Kato et al found laterolisthesis (≥3 mm lateral translation) to be an independent predictor for reoperations (OR = 5.22) in a cohort of patients undergoing minimally invasive decompressions, suggesting the challenge of managing laterolisthesis even with a minimally invasive approach.60 Takahashi et al found that in patients undergoing asymmetrical TLIF for degenerative spondylolisthesis, concurrent local coronal imbalance was associated with significantly worse improvement in VAS back pain than those without local coronal imbalance, despite similar improvement in other clinical outcomes. 23
However, evidence highlights that while laterolisthesis presents surgical challenges, successful reduction can lead to significant functional improvement. A retrospective study investigating adult scoliosis patients found that despite a higher baseline disability, patients with moderate to severe laterolisthesis who achieved an improvement to mild or none after surgery were twice as likely to reach clinically relevant improvement at 2 years compared to those whose laterolisthesis did not improve. 61
Despite these findings supporting fusion surgery on laterolisthesis, high-quality literature on the surgical outcomes of laterolisthesis remains limited. Most studies focus on degenerative spondylolisthesis or laterolisthesis in the context of scoliosis, with few dedicated analyses regarding how isolated laterolisthesis impacts patient-oriented outcomes, fusion success, and complication rates. Critical aspects such as the risk of pseudarthrosis, implant failure, and adjacent segment disease in the setting of laterolisthesis remain underexplored.
Conclusion
Lumbar laterolisthesis presents significant challenges in degenerative lumbar surgery, largely due to its complex dimensionality. Its multifactorial etiology, variable symptomatology, and limited high-quality evidence in literature specific to laterolisthesis further complicate diagnosis and surgical decision-making, leading to a lack of consensus about its impact on surgical outcomes. The optimal surgical approach remains debated, with questions surrounding the role of minimally invasive techniques. Future research should focus on comparing different surgical strategies and their effects on key outcomes, including symptomatic improvement, fusion rates, complication rates, and long-term surgical success.
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Contributors:
Adrian Lui, MBBS1
Amy Z. Lu, BS1,2
Tarek Harhash, BS1
Tomoyuki Asada, MD PhD1,3
Sravisht Iyer, MD1
From the 1Department of Orthopaedics at the Hospital for Special Surgery in New York City, New York; 2Weill Cornell Medical College in New York City, New York; and 3 Department of Orthopedics at the University of Tsukuba Hospital in Tsukuba, Japan.
