Lumbar Retrolisthesis Compensates Spinal Kyphosis

Spine Deformity 7 (2019) 602e609 www.spine-deformity.org

Lumbar Retrolisthesis Compensates Spinal Kyphosis Yuki Mihara, MDa,*, Daisuke Togawa, MD, PhDa, Tomohiko Hasegawa, MD, PhDa, Yu Yamato, MD, PhDa, Go Yoshida, MD, PhDa, Sho Kobayashi, MD, PhDb, Tatsuya Yasuda, MDa, Tomohiro Banno, MD, PhDa, Hideyuki Arima, MD, PhDa, Shin Oe, MDa, Hiroki Ushirozako, MDa, Yukihiro Matsuyama, MD, PhDa a

Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1 Chome-20-1 Handayama, Hamamatsu, Shizuoka Prefecture 431-3125, Japan b Department of Orthopedic Surgery, Hamamatsu Medical Center, 1 Chome-20-1 Handayama, Hamamatsu, Shizuoka Prefecture 431-3125, Japan Received 17 May 2018; revised 18 November 2018; accepted 24 November 2018

Abstract Study Design: Large cohort study. Objective: To investigate the role of lumbar retrolisthesis in spinopelvic alignment and health-related quality of life (HRQOL) among volunteers aged O50 years. Summary of Background Data: Lumbar retrolisthesis pathology has not been sufficiently elucidated. Methods: We included 639 volunteers (257 men, average age 73 [50-92] years). Sagittal vertical axis (SVA), maximum thoracic kyphosis (maxTK), lumbar lordosis (LL), pelvic incidence (PI), and pelvic tilt (PT) were measured using whole-spine and pelvic radiographs taken in standing position. MaxTK was measured from the upper to the lower end vertebrae of spinal kyphosis in the sagittal plane using Cobb’s method. HRQOL was evaluated using the Oswestry Disability Index (ODI). Subjects with >3 mm posterior lumbar vertebral slip and those with multiple retrolisthesis were included in R(þ) and multiple groups, respectively. In single lumbar retrolisthesis subjects, those above L3eL4 were defined as the superior group and below L4eL5 as the inferior group. Results: The R(þ) group had 259 (41%) subjects. Of the posterior slipped vertebrae, 235 (91%) were consistent with the lower end vertebra of the maxTK or its adjacent one. The R(þ) group had significantly more males; subjects were older than those in the R(e) group. They also had significantly greater SVA, TK, maxTK, and PI-LL and smaller LL and PI. Multivariate analysis revealed that sex, maxTK, and LL were independent predictors of lumbar retrolisthesis. The inferior group had a significantly greater SVA, PT and PI-LL, and smaller LL and PI than the R(e), superior, and multiple groups. The inferior group also had significantly worse ODI than the R(e) group. Conclusions: Subjects with lumbar retrolisthesis showed greater spinal kyphosis and worse spinopelvic alignments. Subjects with lowergenerated lumbar retrolisthesis showed worse spinopelvic alignment and HRQOL than subjects with upper-generated lumbar retrolisthesis and multiple ones and those without it. Level of Evidence: Level IV. Ó 2018 Scoliosis Research Society. All rights reserved. Keywords: Lumbar retrolisthesis; Health-related quality of life; Spinopelvic alignment; Whole-spine radiograph; Compensation mechanism

Author disclosures: YM (none), DT (other from Meitoku Medical Institute Jyuzen Memorial Hospital, Japan Medical Dynamic Marketing Inc., and Medtronic Sofamor Danek Inc., during the conduct of the study; personal fees from the Journal of Bone and Joint Surgery, outside the submitted work; SO and DT belong to a donated fund laboratory known as the Division of Geriatric Musculoskeletal Health), TH (none), YY (none), GY (none), SK (none), TY (none), TB (none), HA (none), SO (SO and DT belong to a donated fund laboratory known as the Division of Geriatric Musculoskeletal Health.), HU (none), YM (none).

IRB approval: The study protocol was approved by the institutional review board of Toei Hospital, Aichi, Japan. Funding sources: Medtronic Sofamor Danek, Inc., Japan Medical Dynamic Marketing, Inc., and Meitoku Medical Institute Jyuzen Memorial Hospital. *Corresponding author. Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama Higashi-ku, Hamamatsu, Shizuoka 431-3192, Japan. Tel.: 81-53-435-2299; fax: 81-53-435-2296. E-mail address: [email protected] (Y. Mihara).

2212-134X/$ - see front matter Ó 2018 Scoliosis Research Society. All rights reserved. https://doi.org/10.1016/j.jspd.2018.11.013

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Introduction Spondylolisthesis is the anterior or posterior migration of one vertebra in relation to the next caudal vertebra [1]. Generally, we are more familiar with lumbar anterolisthesis than retrolisthesis. If lumbar anterolisthesis is observed on a lateral radiograph in an outpatient clinic, we check whether the patient has lower back pain and neurologic findings [2] because of its pathology [3-5]. However, if lumbar retrolisthesis is detected, there is no general consensus on what should be done. Although it has been found to be associated with disc degeneration, a decrease in lumbar lordosis, and a decrease in the vertebral endplate angle [6-9], its pathology is still unclear. There are several reports on lumbar retrolisthesis. In a review by Barrey et al. [10], it was reported that lumbar retrolisthesis is one of the compensatory mechanisms contributing to the sagittal alignment of the spine, and it is usually observed at immediately adjacent segments of the kyphotic spine. However, the compensatory mechanism was shown in a case presentation only, and statistical analysis was not performed in this report. Wang et al. [1] examined lumbar spondylolisthesis, including lumbar retrolisthesis, in 3,063 elderly Chinese patients and performed several statistical analyses on this large cohort. However, they used recumbent lumbar spine radiographs, not standing whole-spine radiographs, and thus could not assess the sagittal alignment of the global spine. Furthermore, they did not distinguish between anterolisthesis and retrolisthesis. Jeon et al. [11] investigated degenerative retrolisthesis using standing lateral radiographs of the whole spine. They examined three groups, namely, pure retrolisthesis, pure anterolisthesis, and both groups, but they did not have a control group with no retrolisthesis. Consequently, the pathology of lumbar retrolisthesis has not been sufficiently elucidated. It is necessary to use standing whole-spine radiographs and to have a control group when examining patients with lumbar retrolisthesis. Therefore, the purpose of the present study was to investigate the role of lumbar retrolisthesis on spinopelvic alignment and its impact on health-related quality of life (HRQOL) in volunteers older than 50 years.

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The exclusion criteria were as follows: 1) Cobb angle of 20 or more in the coronal plane; 2) orthopedic pathologies (Scheuermann kyphosis, tumor, infection, etc); 3) undergoing total joint arthroplasty; 4) undergoing instrumented spinal surgery; and 5) unable to stand without assistance. Radiologic assessment The radiographic technique was standardized as follows: 1) the patient was in a standing position and staring straight ahead with the hands on the clavicles; 2) three views were acquired (anteroposterior, lateral craniopelvic, and lateral pelvic); and 3) there is a distance of 1.5 m between the xray tube and radiograph. The digitized radiographs were transferred as Digital Imaging and Communications in Medicine data to a computer and measured using an imaging software (Surgimap Spine; Nemaris Inc., New York City, NY). The radiologic measurements were reviewed by two experienced orthopedic spine surgeons. Measured parameters The measured parameters in the radiographs were as follows: 1) sagittal vertical axis (SVA); 2) thoracic kyphosis (TK: Cobb angle between T5 and T12); 3) maximum thoracic kyphosis (maxTK: measured from the upper end vertebra to the lower end vertebra of spinal kyphosis in the sagittal plane according to the Cobb method); 4) lumbar lordosis (LL: Cobb angle between L1 and S1 superior endplate); 5) pelvic incidence (PI); and 6) pelvic tilt (PT). Lumbar retrolisthesis

Materials and Methods

The volunteers who had 3 mm or more posterior lumbar vertebral slip were assigned to the R(þ) group, and the rest were in the R(e) group. The subjects with multiple retrolisthesis were defined as the multiple group. This 3-mm cutoff point was chosen because this criterion has been used previously and corresponded to a slip of 8%, which was used as a lower limit to define retrolisthesis [12-16]. In single lumbar retrolisthesis subjects, those above L3eL4 were defined as the superior group and below L4eL5 as the inferior group.

Volunteer cohort

Clinical evaluation

The study included 746 volunteers who participated in the Toei town health screening program in 2012. Under the institutional review board (IRB) approval (Toei hospital IRB No. 201201), radiographic analysis and questionnaires soring were performed.

The Oswestry Disability Index (ODI) was used to assess HRQOL [17,18]. The ODI is a scale for measuring the degree of disability and quality of life in a person with lower back pain.

Inclusion/exclusion criteria The inclusion criteria were as follows: 1) age 50 years or older; 2) available whole-spine and pelvic radiographs taken in the standing position; and 3) informed consent for participation in this study.

Statistical analysis SPSS statistical software (version 23; IBM-SPSS, Inc., Chicago, IL) was used for statistical analysis. Statistical analysis was performed by the main author. The unpaired t test was used to analyze the differences between the R(þ) and R(e) groups and between sexes (male vs. female). Binary multiple logistic regression analysis was performed

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to detect meaningful factors for incidence of lumbar retrolisthesis. Chi-square test was used for analyzing correlations of the factors with incidence rates of lumbar retrolisthesis. Analysis of variance followed by the Tukey post hoc test was used to detect differences among the four groups: R(e), R(þ) superior, R(þ) inferior, and R(þ) multiple. Results Among the 746 volunteers considered for participation in this study, 656 were enrolled and 90 were excluded on the basis of study criteria. Eventually, this study included 639 volunteers (258 males, 381 females, average age 73 years [range 50-92 years]). There were 259 (41%) volunteers in the R(þ) group (127 males, 132 females). The vertebrae levels of single lumbar retrolisthesis are summarized in Figure 1. The vertebral levels of multiple lumbar

Fig. 3. Levels of lower end vertebra of maximum thoracic kyphosis (maxTK). The axis represents the number of lower end vertebrae of maxTK.

Table 1 Comparisons between the R(þ) and R(e) groups. Parameters

R(þ) group (n 5 259)

Age (years) Male SVA (mm) TK (  ) maxTK (  ) LL (  ) PI (  ) PT (  ) PI-LL (  ) ODI (%)

74.6 127 (49%) 56.6 35.8 44.9 36.2 46.8 19.2 10.6 13.3

SD

Mean

Fig. 1. Levels of single lumbar retrolisthesis vertebrae. The axis represents the number of each subjects.

7.7 47.3 14.4 17.2 18.9 9.6 10.6 17.1 12.3

R(e) group (n 5 380) Mean

p value

SD

71.4 131 (34%) 42.5 32.1 34.4 42 49.9 17.7 7.9 11.8

8.3 45.7 11.4 12 14.6 9.8 9.5 15.5 12.3

!.001 !.001 !.001 .001 !.001 !.001 !.001 .075 .042 .149

LL, lumbar lordosis; maxTK, maximum thoracic kyphosis; ODI, Oswestry Disability Index; PI, pelvic incidence; PT, pelvic tilt; SD, standard deviation; SVA, sagittal vertical axis; TK, thoracic kyphosis.

Table 2 Logistic regression assessing factors contributing to R(þ) occurrence. Model

Regression coefficient (B)

Standard error of (B)

p value

OR

95% CI

Sex maxTK LL

0.733 0.059 0.030

0.181 0.007 0.006

!.001 !.001 !.001

2.082 1.061 0.970

1.461e2.967 1.046e1.076 0.959e0.982

CI, confidence interval; LL, lumbar lordosis; maxTK, maximum thoracic kyphosis; OR, odds ratio.

retrolisthesis are summarized in Figure 2. The lower end vertebra levels of the maxTK are summarized in Figure 3. Of the subjects with posterior slip vertebra, 235 (91%) were consistent with the lower end vertebra of the maxTK or adjacent to it. Comparison between the R(þ) and R(e) groups

Fig. 2. Levels of multiple lumbar retrolisthesis vertebrae. The axis represents the number of each subjects.

As shown in Table 1, the mean age of the R(þ) and R(e) groups was 74.6 and 71.4 years, respectively. Subjects in the R(þ) group were significantly older than those in the

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Fig. 4. (A) The incidence rate of lumbar retrolisthesis according to maximum thoracic kyphosis (maxTK). Incidence of lumbar retrolisthesis was positively associated with maxTK (p ! .001 chi-square test). The mean value (SD) of maxTK was 38.7 (15.2 ). There were 84 subjects with maxTK !23.5 (the mean e1 SD), 471 subjects with 23.5 < maxTK !53.9 (the mean value þ1 SD), and 84 subjects with maxTK >53.9 . The I bar indicates 95% confidence intervals. (B) The incidence rate of lumbar retrolisthesis according to lumbar lordosis (LL). Incidence of lumbar retrolisthesis was negatively associated with LL (p ! .001 by chi-square test). The mean value (SD) of LL was 39.7 (16.7 ). There were 75 subjects with LL !23.5 (the mean e1 SD), 47 subjects with 23.0 < LL !56.4 (the mean value þ1 SD), and 88 subjects with LL >56.4 . The I bar indicates 95% confidence intervals.

R(e) group (p ! .001). Lumbar retrolisthesis was more frequently observed in males than in females (p ! .001). The mean values for SVA, TK, maxTK, LL, PI, PT, PI-LL, and ODI in the R(þ) and R(e) groups are shown in Table 1. The R(þ) group had a significantly greater SVA, TK, maxTK, and PI-LL (p ! .001, p ! .001, p ! .001, p 5 .042, respectively) and smaller LL and PI (p ! .001 and

p ! .001) than the R(e) group. Multivariate analysis revealed that sex (p ! .001, odds ratio [OR] 5 2.082), maxTK (p ! .001, OR 5 1.061), and LL (p ! .001, OR 5 0.97) were independent predictors of lumbar retrolisthesis (Table 2). Furthermore, maxTK and LL were positively and negatively associated with the incidence of lumbar retrolisthesis, respectively (both p ! .001) (Fig. 4A and B).

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greater SVA, maxTK, PT, and PI-LL (p ! .001, p ! .001, p ! .001, p ! .001, respectively) and smaller PI (p 5 .012) and worse ODI (p 5 .013) than the R(e) group. Moreover, the inferior group showed a significantly greater SVA, PT, and PI-LL (p ! .001, p ! .001, p ! .001,

Comparison among the four groups: R(e), superior, inferior, and multiple group There were 380 subjects in the R(e) group, 153 in the superior group, 25 in the inferior group, and 81 in the multiple group. The inferior group showed a significantly Table 3 Comparison among the four groups: R(e), superior, inferior and multiple group.

n Age (years) Male SVA (mm) TK (  ) maxTK (  ) LL (  ) PI (  ) PT (  ) PI-LL (  ) ODI (%)

R(e) group

superior group

inferior group

multiple group

380 71.4 131 (35%) 42.6 32.1 34.4 42 49.9 17.7 7.9 11.8

153 74.8 79 (52%) 54.1 35.8 43.1 38.7 47.2 17.5 8.6 12.9

25 76.2 6 (24%) 96.3 28.3 47.9 9.3 43.8 31.9 34.4 19.6

81 73.9 81 (52%) 49 37.9 47.4 39.9 46.8 18.4 6.9 12.2

p (ANOVA)

p (Tukey)

!.001

*;b, ***;a

!.001 !.001 !.001 !.001 .001 !.001 !.001 .02

*; a, ***;b,d,f *;a,d, **;f,c ***;a,b,c ***;b,d,f *;a,b,c ***;b,d,f ***;b,d,f *;b

ANOVA, analysis of variance; LL, lumbar lordosis; maxTK, maximum thoracic kyphosis; ODI, Oswestry Disability Index; PI, pelvic incidence; PT, pelvic tilt; SVA, sagittal vertical axis; TK, thoracic kyphosis. Multiple comparison a: R(e) vs superior, b: R(e) vs inferior, c: R(e) vs multiple, d: superior vs inferior, e: superior vs multiple, f: inferior vs multiple *p ! .05, **p ! .01, ***p ! .001. Table 4 Comparison between sexes (males vs females). Male (n 5 258)

Parameters

Female (n 5 381) SD

Mean 73.1 127 (49%) 47.9 32.7 37 41.1 46.3 14.1 5.2 10.7

Age (years) R(þ) group SVA (mm) TK (  ) maxTK (  ) LL (  ) PI (  ) PT (  ) PI-LL (  ) ODI (%)

Mean

8.5

SD

72.4 131 (34%) 48.4 34.2 39.9 38.7 50.3 21.1 11.6 13.6

44.7 10.1 11.7 13.8 8.5 7.8 12.9 11.7

p value

8.0

.32 !.001 .711 .760 .832 .434 !.001 !.001 5.001 .014

48.4 14.3 17.1 13.4 10.4 10.4 17.7 12.8

LL, lumbar lordosis; maxTK, maximum thoracic kyphosis; ODI, Oswestry Disability Index; PI, pelvic incidence; PT, pelvic tilt; SD, standard deviation; SVA, sagittal vertical axis; TK, thoracic kyphosis.

Table 5 Comparison between R(þ) and R(e) group in each sexes. Parameter

Male (n 5 258) R(þ) group (n 5 127)

Age (years) SVA (mm) TK (  ) maxTK (  ) LL (  ) PI (  ) PT (  ) PI-LL (  ) ODI (%)

73.5 51.7 35.8 43.8 38.8 46.3 17.3 7.5 12.0

        

7.9 42.4 13.9 16.5 18.9 8.5 10.4 17.0 11.9

Female (n 5 381) R(e) group

p value

R(þ) group

R(e) group

(n 5 132)

(n 5 249)

.219 .346 .006 !.001 .138 .451 .007 .248 .157

75.7 61.2 35.7 46.0 33.7 47.3 21.0 13.6 14.5

(n 5 131) 72.3 46.6 31.9 34.2 41.8 46.9 14.1 5.1 10.0

        

8.3 47.2 8.6 9.9 12.4 7.9 7.8 13.0 11.7

        

7.3 51.2 14.9 17.9 18.6 10.6 10.5 16.6 13.2

70.9 40.1 32.2 34.6 42.2 51.5 19.7 9.4 12.8

        

p value

8.2 45.0 12.7 12.9 15.6 10.4 9.8 16.6 12.5

!.001 !.001 .019 !.001 !.001 .015 .217 .016 .227

LL, lumbar lordosis; maxTK, maximum thoracic kyphosis; ODI, Oswestry Disability Index; PI, pelvic incidence; PT, pelvic tilt; SVA, sagittal vertical axis; TK, thoracic kyphosis.

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respectively) than the superior and multiple groups. The superior and multiple groups showed a significantly greater TK (p 5 .011, p 5 .001) and maxTK (p < .001, p ! .001) and smaller PI (p 5 .012, p 5 .047) than the R(e) group. There was no significant difference between the superior and multiple group (Table 3). Comparison between sexes (male vs. female) There were 258 males and 381 females. Lumbar retrolisthesis tended to occur more frequently in males (p ! .001). Males showed significantly smaller PI than females (p ! .001). Females showed significantly larger PT and PILL than males (p ! .001 and p 5 .001) (Table 4). Comparison between R(þ) and R(e) group in each sex The mean values for age, SVA, TK, maxTK, LL, PI, PT, PI-LL, and ODI in males and females of the R(þ) and R(e) groups are shown in Table 5. In males, the R(þ) group showed significantly greater TK, maxTK, and PT (p 5 .006, p ! .001, p 5 .007, respectively). In females, the R(þ) group was oldeR(p ! .001) and showed significantly greater SVA, TK, maxTK, and PI-LL (p ! .001, p 5 .019, p ! .001, p 5 .016, respectively) and smaller LL and PI (p ! .001, p 5 .015) (Table 5). Discussion In this study, lumbar retrolisthesis occurred in 32% of the volunteers older than 50 years. If subjects with multiple lumbar retrolisthesis were included, the incidence rate can reach 41%. Jeon et al. [11] reported an incidence rate of 29% in surgical cases of lumbar degenerative disease. Lumbar retrolisthesis tended to occur at a higher rate in our study, which may be because the average age of subjects in this study was higheR(73 years) than in Jeon’s [11] (65 years); thus, there is a greater occurrence of lumbar retrolisthesis, a degenerative change in the lumbar spine [19,20], in this study. This suggestion is supported by the finding that the R(þ) group showed a significantly higher average age than the R(e) group in this study. Therefore, lumbar retrolisthesis tended to occur in older-aged subjects. On the other hand, Wang et al. [1] reported the incidence rate of lumbar retrolisthesis to be 10% in volunteers older than 65 years (average age 76 years), which was lower than that observed in our study. However, they used recumbent lumbar spine radiographs, not standing whole-spine radiographs. As lumbar retrolisthesis is one of the compensatory mechanisms contributing to keep the sagittal alignment of the spine, it occurs more in the standing posture than in the recumbent posture. The R(þ) group had a significantly greater SVA, TK, maxTK, and PI-LL than the R(e) group. In other words, subjects with lumbar retrolisthesis tended to have a curved and kyphotic spine with decreased lumbar lordosis. It is

Fig. 5. The spine above the posterior slipped vertebra exhibits kyphosis. The dotted line surrounds the posterior slipped vertebra.

necessary to take whole-spine standing radiographs in lumbar retrolisthesis cases as it is difficult to evaluate a curved and kyphotic spine in local lumbar radiographs. As mentioned above, the average age was also significantly higher in the R(þ) group than in the R(e) group. Therefore, we speculate that lumbar retrolisthesis accompanies age-related deteriorations of the spinal alignment. Lumbar retrolisthesis was observed at lower adjacent segments of the spinal kyphosis [10]. In this study, 91% of posterior slipped vertebra were consistent with the lower end vertebra of the maxTK or adjacent to it in this study. The inferior group showed a significantly greater SVA, PI-

Fig. 6. Lumbar lordosis is decreased more in the inferior group than in the superior group.

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Fig. 7. (A) L4eL5 retrolisthesis is observed in a lateral lumbar radiograph. (B) Sagittal malalignment is observed in a standing whole-spine radiograph.

LL, and PT than the R(e), superior, and multiple group. As mentioned above, lumbar retrolisthesis is mostly observed at the lower end vertebra of the maxTK or adjacent to it. The spine above the posterior slipped vertebra exhibits kyphosis (Fig. 5). Therefore, lumbar lordosis was more decreased in the inferior group than in the other groups as the spine curved forward and the pelvis tilted backward (Fig. 6). The worse HRQOL in the lower group might be due to these spinopelvic malalignments. Figure 7A and B are radiographs of a typical lower-generated lumbar retrolisthesis case. If we noted this kind of lumbar retrolisthesis in radiographs, spinal alignments should be evaluated using whole-spine radiographs in standing position. The R(þ) group showed a significantly smaller PI than the R(e) group. Previously, it was reported that low PI is associated with flat lumbar spine and high PI with more curved lumbar spine [21]. In this study, the R(þ) group showed large spinal kyphosis, or high maxTK. To compensate this large spinal kyphosis, hyper lumbar lordosis is needed. However, low-PI subjects tend to be flat lumbar spine, not hyperlordotic. Then, the lumbar vertebra might shift and tilt posteriorly to create more lumbar lordosis. This hypothesis is supported by the finding that lumbar retrolisthesis was more frequently observed in males. Indeed, males also showed lower PI than females. On the other hand, spinopelvic parameters were more deteriorated in females. Oe et al. [22] reported that the PI-LL and PT in females tended to be larger than in males among elderly volunteers. Thus, the pathology of deterioration of spinopelvic alignment also might be different between males and females. Moreover, spinopelvic parameters were more deteriorated in the R(þ) group of females, not males. Therefore, the pathology of

lumbar retrolisthesis might be also different between males and females. There were some limitations in this study. First, the study cohort consisted exclusively of Japanese subjects older than 50 years. Therefore, it is unclear whether these data are applicable to other races. Second, most volunteers who participated in this study live in a mountainous area and were engaged in agriculture, which may differ from the environments in urban areas. Third, this study had a small number of subjects, especially in the subanalyses according to the levels of lumbar retrolisthesis or sexes. Therefore, more thorough investigations should be done in the near future. Fourth, this study had a cross-sectional design; thus, we could not determine the pathology of lumbar retrolisthesis. Therefore, further longitudinal studies are warranted to clarify whether increased spinal kyphosis induces lumbar retrolisthesis. In conclusion, subjects with lumbar retrolisthesis showed greater spinal kyphosis and worse spinopelvic alignments. Subjects with lower-generated lumbar retrolisthesis showed worse spinopelvic alignment and HRQOL than subjects with upper-generated lumbar retrolisthesis and multiple ones and those without it. Key points  Lumbar retrolisthesis was observed in 41% of total volunteers older than 50 years in whole-spine standing radiographs and showed worse spinal alignment and HRQOL.  Approximately 91% of posterior slipped vertebrae were consistent with the lower end vertebrae or its adjacent ones.

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