Clin Orthop Relat Res (2019) 00:1-4
DOI 10.1097/CORR.0000000000001005
In Brief
Classification in Brief: The Spinal Deformity Study Group
Classification of Lumbosacral Spondylolisthesis
Gaston Camino Willhuber MD, Gonzalo Kido MD
Received: 21 July 2019 / Accepted: 3 October 2019 / Published online: 18 October 2019
Copyright © 2019 by the Association of Bone and Joint Surgeons
History
Spondylolisthesis is characterized by vertebral slippage
from a variety of causes, including degenerative changes,
trauma, tumors or congenital dysplasia. Isthmic spondy-
lolisthesis is an acquired condition that results from a pars
interarticularis disruption usually at the L5 vertebra that
exhibits a similar male:female distribution. The most
common symptoms are low back pain and unilateral or
bilateral leg pain caused by L5 radiculopathy, depending
on severity.
The first classification of spondylolisthesis was de-
veloped by Meyerding [14] in 1932, who described four
types depending on the degree of slippage between two
vertebral bodies. In that classification, Grade I involved a
slip of 0% to 25%, Grade II was defined as 25% to 50%,
Grade III as 50% to 75%, and Grade IV as 75% to 100%.
Later, a Grade V was added with a slip greater than 100%
slippage (a condition called spondyloptosis). In 1976,
Wiltse et al. [17] described a classification based on etio-
logical and anatomical factors with 5 types: I-dysplastic
Each author certifies that neither he, nor any member of his im-
mediate family, has funding or commercial associations (consul-
tancies, stock ownership, equity interest, patent/licensing
arrangements, etc.) that might pose a conflict of interest in con-
nection with the submitted article.
All ICMJE Conflict of Interest Forms for authors and Clinical Or-
thopaedics and Related Research® editors and board members are
on file with the publication and can be viewed on request.
Each author certifies that his institution waived approval for the
reporting of this investigation and that all investigations were
conducted in conformity with ethical principles of research.
G. Camino Willhuber, G. Kido, Institute of Orthopedics “Carlos E.
Ottolenghi” Hospital Italiano de Buenos Aires, Buenos Aires,
Argentina
G. Camino Willhuber (✉), Potosı́ 4215 (C1199ACK), Buenos Aires,
Argentina, E-mail: gaston.camino@hospitalitaliano.org.ar
Copyright © 2019 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
(congenital); II-isthmic (described as a pars lysis (type
IIA), a pars elongation (type IIB) or an acute pars fracture
(type IIC); III-degenerative; IV-traumatic and V-neoplastic
conditions. This system was useful in terms of etiology.
Marchetti and Bartolozzi [13] distinguished between de-
velopmental and acquired forms of spondylolisthesis and
divided developmental spondylolisthesis into two major
types, high- and low-dysplastic, depending on the severity of
bony dysplastic changes of the lumbosacral region and the
risk of further slippage. The high-dysplastic type is mainly
associated with substantial lumbosacral kyphosis, a trape-
zoidal L5 vertebra, dysplastic posterior elements of L5 and
S1, and an anomaly of the upper endplate of S1. By contrast,
the low-dysplastic type corresponds to minimal lumbosacral
kyphosis, almost rectangular L5 vertebra, minimal sacral
doming and relatively normal transverse processes. Al-
though they introduced the concept of low and high dys-
plasia in the classification, they did not provide strict criteria
on how to differentiate between these two subtypes.
Many studies demonstrated the importance of global
and spinopelvic balance, mainly assessed through radio-
graphic measurements such as pelvic incidence, sacral
slope, pelvic tilt, sagittal vertical axis, and lumbar lordosis
in the evaluation and progression of spondylolisthesis [2, 4,
7]. The relationship between pelvic and global balance and
spondylolisthesis progression has garnered more interest
recently. Glassman et al. [3] and Mac-Thiong et al. [12]
demonstrated a direct relationship between sagittal balance
and health-related quality of life in patients with spinal
deformity. In addition, the relationship between pelvic and
global balance with spondylolisthesis progression has
garnered more interest recently [5]. For this reason, the
Spinal Deformity Study Group developed a classification
system that consists of six types of progressive lumbosacral
spondylolisthesis based on radiographic parameters such
as pelvic incidence, slip grade, and sacropelvic and spinal
balance, and proposed a therapeutic guide for the man-
agement of these different types depending on spondylo-
listhesis severity.
 2 Camino Willhuber & Kido Clinical Orthopaedics and Related Research®

Purpose sacral slope) are subclassified according to normal or ab-

Different classification schemes have been proposed to
describe lumbosacral spondylolisthesis; however, most
guidelines were based only on slip grade. Mac-Thiong et al.
[9] proposed a classification based on radiographic meas-
urements that included slip grade and spinopelvic align-
ment (pelvic incidence, sacropelvic balance, and spinal
balance); this classification has been shown to have sub-
stantial intra- and interobserver agreement.
The Spinal Deformity Study Group classification
scheme, now widely used among spine surgeons, evaluates
the severity of lumbosacral spondylolisthesis to improve
the clinical management and surgical planning of lumbo-
sacral spondylolisthesis.
Description
The classification of the Spinal Deformity Study Group
developed by Mac-Thiong et al. [9] describes six types of
lumbosacral spondylolisthesis based on slip grade and
sacropelvic and global spinopelvic balance (Table 1). This
classification is not used for degenerative spondylolisthesis
or L4-L5 pathology.
Grades are described in increasing order of severity and
risk of progression. To classify spondylolisthesis, the first
step is to quantify the degree of slip on a lateral radiograph
and distinguish low-grade (less than 50% translation) and
high-grade (more than 50% translation) according to the
Meyerding [14] classification. The second step is to assess
the sacropelvic balance, measuring the pelvic incidence,
pelvic tilt, and sacral slope. Finally unbalanced sacropelvic
cases (high pelvic tilt/low sacral slope) are subclassified
according to the global spinopelvic balance, making six
spondylolisthesis types.Finally, patients with unbalanced
sacropelvic spondylolisthesis (high pelvic tilt and low
normal global spinopelvic balance; this creates a classifi-
cation with six spondylolisthesis types. Normal
spinopelvic balance is defined as a plumb line from C7 that
falls at or behind the femoral heads. Abnormal spinopelvic
balance has a plumb line that falls anterior to the femoral
heads. In all low-grade slips, global spinopelvic balance is
noted to be normal, as is sacropelvic balance.
Type 1 has low-grade spondylolisthesis and low pelvic
incidence (less than 45°) (Fig. 1).Type 2 has low-grade
spondylolisthesis and normal pelvic incidence (45° to
60°).Type 3 has low-grade spondylolisthesis and high
pelvic incidence (more than 60°).Type 4 has high-grade
spondylolisthesis and balanced sacropelvic parameters
(low pelvic tilt /high sacral slope).Type 5 has high-grade
spondylolisthesis with unbalanced sacropelvic parameters
(high pelvic tilt/low sacral slope) and balanced spinopelvic
parameter (plumb line at or posterior to the femoral
heads).Type 6 has high-slip-grade spondylolisthesis with
unbalanced sacropelvic parameters (high pelvic tilt/low
sacral slope) and an unbalanced spinopelvic parameter
(plumb line anterior to femoral heads).
Validation
The first description of the classification was proposed by
the Spinal Deformity Study Group in 2006 [10]. The
authors incorporated the concept of sagittal and spinopel-
vic balance and described a scheme to guide surgical
treatment of developmental spondylolisthesis in children,
adolescents, and young adults. The original description
proposed slip grade, spinopelvic balance, and degree of
bony dysplasia that considered eight different grades of
spondylolisthesis. However, after a validation study [11],
only fair inter-rater reliability was found (kappa [k] = 0.49)
mainly due to the difficulty assessing the dysplasia on

Table 1. Spinal Deformity Study Group classification of spondylolisthesis

Type Slip grade Sacropelvic balance Global spinopelvic balance
Type 1 < 50% Low pelvic incidence (< 45°)
Type 2 < 50% Normal pelvic incidence (45°-60°)
Type 3 < 50% High pelvic incidence (> 60°)
Type 4 > 50% Balanced (high sacral slope/low
pelvic tilt)
Type 5 > 50% Retroverted (low sacral slop/high Balanced (C7 plumb line between the
pelvic tilt) femoral heads and sacrum)
Type 6 > 50% Retroverted (low sacral slope/high Unbalanced (C7 plumb line anterior to
pelvic tilt) the femoral head or posterior to the
sacrum)
Adapted with permission from Mac-Thiong JM, Labelle H, Parent S, Hresko MT, Deviren V, Weidenbaum M, members of the Spinal
Deformity Study Group. Reliability and development of a new classification of lumbosacral spondylolisthesis. Scoliosis. 2008;3:19.

Copyright © 2019 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 00, Number 00
Fig. 1 This figure shows (A) Type 1, (B) Type 2, (C) Type 3, (D) Type 4, (E) Type 5, and (F) Type 6 spondylolisthesis as classified by the
Spinal Deformity Study Group classification. Used with permission from Franco De Cicco MD.
radiograph (k = 0.43). Based on these preliminary results,
the Spinal Deformity Study Group removed dysplasia
grades from the classification. In 2009, the final six-type
description was presented based results from a multicenter
radiographic database that included 816 patients between
10 and 40 years old; data was collected from 43 spine
surgeons in North America and Europe [6].
Once the classification was published [6], validation
studies were conducted. In 2012, Mac-Thiong et al. [9]
reported substantial reliability of the Spinal Deformity Study
Group classification in a study with 40 adolescents with
spondylolisthesis. In this study, a computer-assisted tech-
nique was developed to facilitate the parameter’s measure-
ment and improve its accuracy because the authors believed
that computer assistance might minimize technical errors in
evaluation. However, this belief could not be validated be-
cause software use did not improve the reliability of the
spinopelvic measurements [1, 9]. In 2015, Bao et al. [1]
evaluated 80 patients with isthmic (70 patients) and dys-
plastic (10 patients) L5-S1 spondylolisthesis and showed
substantial intraobserver and interobserver agreement of
86% (k = 0.83) and 73% (k = 0.64), respectively [1].
This classification also provides recommendations
regarding slippage reduction in patients with high degrees
of spondylolisthesis (types 4, 5, and 6) [6]. The authors
recommended the following: no reduction in type 4,
attempted reduction when possible in type 5, and re-
duction and realignment in type 6 deformities to restore
spinopelvic and global balance. The rationale for this is
that correction of spinopelvic and global parameters has
been associated with pain relief and better quality of life in
spinal deformity [6, 15, 16].
Copyright © 2019 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
nnn 3
Limitations
We are aware of only two studies that evaluated the re-
liability of the Spinal Deformity Study Group classifica-
tion; they both showed generally good reliability [1, 9].
Importantly, both studies showed disagreement between
observers, especially when differentiating among patients
with low-grade spondylolisthesis (types 1, 2, and 3). In
Mac-Thiong et al. [9], the corresponding kappa was 0.63;
Bao et al. [1] found similar results with kappa of 0.60 when
classifying types 1, 2 and 3. According to the Spinal De-
formity Study Group classification, low-grade spondylo-
listhesis was subdivided based on pelvic incidence, with an
interval of 15° between the three subgroups (pelvic in-
cidence < 45° in Type 1, pelvic incidence between 45° and
60° in Type 2 and pelvic incidence > 60° in Type 3);
considering the systematic measurement error of 5°, these
factors may contribute to the disagreement in both studies.
Another limitation of the classification is the difficulty
evaluating patients with dysplastic spondylolisthesis; it is
challenging to recognize the anterior and posterior sacral
points because of the presence of the sacral dome. Both
validation studies, Mac-Thiong et al. [9] and Bao et al. [1]
included patients with dysplastic spondylolisthesis; how-
ever, they did not calculate reliability separately in the
different subgroups (isthmic and dysplastic).
A final limitation is that only a few outcomes studies have
determined the clinical results of treatment using this clas-
sification system. For example, Hresko et al. [5] highlighted
the importance of reduction in unbalanced cases of spon-
dylolisthesis, and Labelle et al. [6] reviewed research from
the Spinal Deformity Study Group based on the analysis of
 4 Camino Willhuber & Kido
816 subjects. However, a key limitation in all of these studies
is the absence of long-term follow-up, and because of that,
we recommend taking considerable caution when using this
classification schema to guide treatment.
Conclusions
Although the Spinal Deformity Study Group Classification
seems promising, we still lack robust clinical outcome
studies to support the recommendations that have been made
by the authors. Until those studies appear, we suggest caution
about adopting the classification or these recommendations.
Although two studies showed substantial reliability [1, 8],
there was some disagreement, especially when classifying
low-grade spondylolisthesis. In particular, we note that even
in the better of those studies, there was disagreement between
observers in the classification of about 1 in 8 patients with
spondylolisthesis [1]. In the other study, it was more than 1 in
4 [8]. This can have important implications for treatment,
prognosis, research, and communication among providers.
Acknowledgments We thank Franco De Cicco MD, for his valuable
contribution on the figure.
References
1. Bao H, Yan P, Zhu W, Bao M, Li Y, Zhang Z, Qiu Y, Zhu F.
Validation and reliability analysis of the Spinal Deformity Study
Group Classification for L5-S1 Lumbar Spondylolisthesis. Spine
(Phila Pa 1976). 2015;40:E1150-1154.
2. Duval-Beaupere G, Schmidt C, Cosson P. A barycentremetric
study of the sagittal shape of spine and pelvis: the conditions
required for an economic standing position. Ann Biomed Eng.
1992;20:451462.
3. Glassman SD, Bridwell K, Dimar JR, Horton W, Berven S,
Schwab F: The impact of positive sagittal balance in adult spinal
deformity. Spine (Phila Pa 1976). 2005;30:2024-2029.
4. Hanson DS, Bridwell KH, Rhee JM, Lenke LG: Correlation of
pelvic incidence with low- and high-grade isthmic spondylolis-
thesis. Spine (Phila Pa 1976). 2002;27:2026-2029.
Copyright © 2019 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
Clinical Orthopaedics and Related Research®
5. Hresko MT, Labelle H, Roussouly P, Berthonnaud E. Classifi-
cation of high-grade spondylolistheses based on pelvic version
and spine balance: possible rationale for reduction. Spine (Phila
Pa 1976). 2007;32:2208-2213.
6. Labelle H, Mac-Thiong JM, Roussouly P. Spino-pelvic sagittal
balance of spondylolisthesis: a review and classification. Eur
Spine J. 2011;20(Suppl 5):641-646.
7. Legaye J, Duval-Beaupere G, Hecquet J, Marty C. Pelvic in-
cidence: a fundamental pelvic parameter for three-dimensional
regulation of spinal sagittal curves. Eur Spine J. 1998;7:99-103.
8. Li Y, Hresko MT. Radiographic analysis of spondylolisthesis
and sagittal spinopelvic deformity. J Am Acad Orthop Surg.
2012;20:194-205.
9. Mac-Thiong JM, Duong L, Parent S, Hresko MT, Dimar JR,
Weidenbaum M, Labelle H. Reliability of the Spinal Deformity
Study Group classification of lumbosacral spondylolisthesis.
Spine (Phila Pa 1976). 2012;37:E95–102.
10. Mac-Thiong J-M, Labelle H. A proposal for a surgical classifi-
cation of pediatric lumbosacral spondylolisthesis based on cur-
rent literature. Eur Spine J. 2006;15:1425-1435.
11. Mac-Thiong JM, Labelle H. Reliability and development of a
new classification of lumbosacral spondylolisthesis. Scoliosis.
2008;3:19.
12. Mac-Thiong JM, Transfeldt EE, Mehbod AA, Perra JH, Denis
F, Garvey TA, Lonstein JE, Wu C, Dorman CW, Winter RB.
Can c7 plumbline and gravity line predict health related quality
of life in adult scoliosis? Spine (Phila Pa 1976). 2009;34:
E519-27.
13. Marchetti PC, Bartolozzi P. Classification of spondylolisthesis
as a guideline for treatment. In: Bridwell KH, DeWald RL, eds.
The Textbook of Spinal Surgery. 2nd ed. Philadelphia, PA: Lip-
pincott-Raven; 1997:1211-1254.
14. Meyerding HW. Spondylolisthesis. Surg Gynecol Obstet. 1932;
54:371-377.
15. Schwab F, Patel A, Ungar B, Farcy JP, Lafage V. Adult spinal
deformity-postoperative standing imbalance: how much can you
tolerate? An overview of key parameters in assessing alignment
and planning corrective surgery. Spine. 2010;35:2224-2231.
16. Videbaek TS, Bünger CE, Henriksen M, Neils E, Christensen
FB. Sagittal spinal balance after lumbar spinal fusion: the impact
of anterior column support results from a randomized clinical
trial with an eight- to thirteen-year radiographic follow-up. Spine.
2011;36:183-191.
17. Wiltse LL, Newman PH, Macnab I. Classification of spondy-
lolysis and spondylolisthesis. Clin Orthop Relat Res. 1976;117:
23-29.