Clinical Radiology (2005) 60, 533–546

PICTORIAL REVIEW

The imaging of lumbar spondylolisthesis

S. Butta, A. Saifuddina,b,*
a
Department of Radiology, Royal National Orthopaedic Hospital NHS Trust, Stanmore, Middlesex HA7 4LP,
UK; and bInstitute of Orthopaedics and Musculo-Skeletal Sciences, University College, London, UK

Received 9 May 2004; received in revised form 17 July 2004; accepted 26 July 2004

KEYWORDS Lumbar spondylolisthesis is a common finding on plain radiographs. The condition has
Spondylolisthesis; a variety of causes which can be differentiated on the basis of imaging findings. As the
Spondylolysis; treatment is dependent upon the type of spondylolisthesis, it is important for the
Lumbosacral region; radiologist to be aware of these features. We present a pictorial review of the
Radiography; imaging features of lumbar spondylolisthesis and explain the differentiating points
Magnetic resonance between different groups of this disorder. The relative merits of the different
(MR) imaging techniques in assessing lumbar spondylolisthesis are discussed.
q 2004 The Royal College of Radiologists. Published by Elsevier Ltd. All rights
reserved.

Introduction by one of two methods.3 The first is the method of

Spondylolisthesis is defined as anterior displacement
of a vertebra relative to the vertebra below, whereas
the reverse, when the superior vertebra slips
posterior to that below, is named retrolisthesis. The
term spondylolisthesis was first used by Killian in
1853; the condition may result when a component of
the vertebral neural arch is compromised. Once
lateral radiographs have indicated the presence of
spondyloslisthesis, a decision as to its aetiology and
degree must be made, as well as to the cause of any
associated nerve root compression. Since both
spondylolysis and spondylolisthesis may be asympto-
matic, the radiologist can also play a role in
identifying the causes of low back and leg pain,
which may arise from differing spinal segments.
The classification of lumbar spondylolisthesis
was made by Wiltse et al.1 in 1976. A revised
version is presented in Table 1.2
Grading of lumbar spondylolisthesis
The forward slip of the vertebra above is measured
* Guarantor and correspondent: A. Saifuddin, Department of
Radiology, Royal National Orthopaedic Hospital NHS Trust,
Stanmore, Middlesex HA7 4LP, UK. Tel.: C44 208 909 5443;
fax: C44 208 909 5281.
E-mail address: asaifuddin@aol.com (A. Saifuddin).
Myerding. The anteroposterior (AP) diameter of the
superior surface of the lower vertebra is divided
into quarters and a grade of I–IV is assigned to slips
of one, two, three or four quarters of the superior
vertebra, respectively (Fig. 1a). The other method,
first described by Taillard, expresses the degree of
slip as a percentage of the AP diameter of the top of
the lower vertebra (Fig. 1b). Complete slip of L5 on
S1 is termed spondyloptosis (Fig. 1c). The second
method is favoured by most authors as it is more
accurately reproducible. Measurement of the slip
and its apparent progression, however, should be
viewed with caution. Studies have shown that there
can be inter- and intra-observer error of up to 15%.
This variation can increase if there is an element of
rotation. Therefore, only a progression of greater
than 20% slip can be reliably assessed.4,5
Table 1 Aetiology of lumbar spondylolisthesis1,2
Type Cause
Dysplastic Congenital dysplasia of articular processes
Isthmic Defect in pars articularis
Degenerative Degenerative changes in facet joints
Traumatic Fracture of neural arch other than pars
interarticularis
Pathological Weakening of neural arch due to disorders
of bone
Iatrogenic Excessive removal of bone following spinal
decompression

0009-9260/$ - see front matter q 2004 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.crad.2004.07.013
534
Figure 1 Methods of grading lumbar spondylolisthesis.
(a) The method of Myerding: lateral radiograph of the
lumbosacral junction in type 1 spondylolisthesis shows a
Grade III slip. (b) The method of Taillard: lateral radio-
graph of the lumbosacral junction shows a type 2
spondylolisthesis with an approximately 158 slip. (c)
Spondyloptosis of L5 on S1. Note the wide defect in the
pars interarticularis (arrow).
S. Butt, A. Saifuddin
Classification of lumbar spondylolisthesis
Type 1, dysplastic (congenital)
spondylolisthesis
Three subtypes have been described under this
heading.
Type 1a. The articular processes of L5 and S1 are
dysplastic, having a horizontal rather than coronal
orientation. There is rounding of the superior
vertebral endplate of S1 and there may be spina
bifida occulta affecting S1 or L5 or both.
Type 1b. The orientation of the facet joints is
sagittal and the facets are malformed, allowing
spondylolisthesis to occur typically in adult life.
Type 1c includes other congenital malformations
of the lumbar spine which permit spondylolisthesis.
Type 1a dysplastic spondylolisthesis has been
reported in babies.6 It is most commonly seen in
young patients, being typically asymptomatic in
childhood and producing symptoms of low back pain
in adolescence. It accounts for 14–21% of all
spondylolistheses.7 In trying to establish a heredi-
tary basis for this condition, radiographs obtained
of first-degree relatives of patients with dysplastic
and isthmic varieties of spondylolisthesis demon-
strated that up to 19% of the relatives showed a
defect which was of the opposite type from that of
the patient.8 This indicates an overlap in the
hereditary patterns of these two entities. The
radiographic features of type 1a are classical: on
the AP view, the forward slip and tilt of the L5
vertebral body results in an axial image through the
vertebra, producing the ‘Napoleon’s hat’ sign (Fig.
2a). On the lateral radiograph, there is usually a
high-grade slip. Posterior wedging of L5 and round-
ing of the superior endplate of S1 are common
findings (Fig. 2b). The pars may be elongated and
intact or fragmented (Fig. 2b). Spina bifida occulta
is a relatively common associated finding. The
status of the pars is best defined on sagittal CT
multiplanar reconstructions (MPR), but can also be
demonstrated on MRI as can degeneration and
pseudo-bulging of the lumbosacral disc (Fig. 3).
Depending upon the degree of slip, L5 root
compression may be evident in the L5/S1 inter-
vertebral foramen (Fig. 3b). There may also be
severe compression of the cauda equina between
the neural arch of L4 and the posterosuperior
margin of the sacrum (Fig. 3a).
Type 1b dysplastic spondylolisthesis is usually
seen in adults. In patients with a more sagittal
orientation of the L5/S1 facets, the slip can occur in
the presence of an intact bony ring, possibly
resulting in significant neurological compromise in
The imaging of lumbar spondylolisthesis
Figure 2 Type 1a dysplastic spondylolisthesis. (a)
Anteroposterior radiograph demonstrates the ‘Napoleon’s
hat’ sign. (b) Lateral radiograph demonstrates approxi-
mately 70% slip, with posterior wedging of L5 and
rounding of the superior endplate of S1. Note the pars
defect of L5 (arrows).
535
Figure 3 Type 1a dysplastic spondylolisthesis. (a)
Midline sagittal T2W FSE MRI demonstrates a degen-
erate pseudobulging lumbosacral disc with severe
compression of the cauda equina between the neural
arch of L4 and the superoposterior aspect of the
sacrum. (b) Parasagittal T1W SE MRI at the level of
the intervertebral foramen shows severe compression
of the exiting L5 nerve root.
536 S. Butt, A. Saifuddin

Figure 4 Type 1b dysplastic spondylolisthesis in an adult. (a) Sagittal T1W SE MRI demonstrates a grade 1
spondylolisthesis. The L4/5 and L5/S1 discs are degenerate. (b) Parasagittal T1W SE MRI demonstrates marked
hypoplasia of the S1 superior articular facet and elongation of the L5 pars interarticularis. (c) Axial T1W SE MRI
demonstrates a dysplastic L5 neural arch. Note also the asymmetry of facet joint orientation (facet tropism).
The imaging of lumbar spondylolisthesis
the presence of a small degree of slip. It is the
dysplastic nature of the facets and their rotation,
which is frequently asymmetrical between the two
sides (Fig. 4), which differentiate this type from
degenerative spondylolisthesis.9
Type 1c includes congenital kyphosis, which
typically occurs at the thoracolumbar junction,
and various other congenital anomalies of the
lumbar neural arch such as congenital absence of
the articular processes (Fig. 5).
Type 2, isthmic (lytic) spondylolisthesis
The pars interarticularis is the part of the neural
arch that joins the superior and inferior articular
processes. Isthmic spondylolisthesis occurs in the
presence of bilateral pars defects, which can result
from a variety of causes.10,11 Wiltse, in his original
description, divided this category into three
subtypes.1
In type 2a, lytic defects arise in the pars because
of congenital weakness in the bone or repeated
mechanical strain or both. These defects are not
present at birth. Below the age of 50 years this is
the commonest cause of lumbar spondylolisthesis.
The incidence of such defects in 7-year-olds is
approximately 5%, increasing by 0.8% at 17 years.12
The incidence of spondylolisthesis increases from
5–6% in the general population to 35% in families
where one member has spondylolysis or spondylo-
listhesis.8,13 The male:female ratio is 2:1, with L5/
S1 being the commonest segment affected and 90%
of the cases occurring in the lumbar spine.12 Both
spondylolysis and spondylolisthesis can be
asymptomatic, or presentation can be with low
back or leg pain or both. The diagnosis is
evident on the coned lateral radiograph of the
lumbosacral junction, which demonstrates the
typically mild to moderate degree of slip
together with loss of disc height and established
bilateral pars defects (Fig. 6). CT is not
routinely required for diagnostic purposes,
although sagittal CT MPR can demonstrate the
detail of the pars defects. Scintigraphy has no
role in diagnosis of lytic spondylolisthesis.
In type 2b, the elongated pars is a true stress
fracture of the pars. Repeated trauma results in
microfractures and, when these fractures heal, the
pars elongates and thus can no longer check the
forward movement of the vertebrae. This is a very
rare condition.
In type 2c, the pars fractures under acute trauma
in cases which show complex fractures of the spine.
Acute isolated pars fracture is exceedingly rare.
537
The role of MRI in differentiation
The role of MRI is twofold. First, in the setting of
significant low back pain which may necessitate
lumbar spinal fusion, MRI can demonstrate adjacent
segment degenerative disc disease (Fig. 7a). In this
situation, preoperative discography may be indi-
cated to determine whether adjacent degenerate
discs are a source of low back pain. Secondly, in the
setting of lumbar radiculopathy, MRI can reliably
demonstrate the site and cause of nerve root
compression. Studies have shown a good correlation
between nerve root impingement and clinical signs
of radiculopathy.14 Nerve root compression in lytic
spondylolisthesis typically occurs in the foramen,
due to a combination of reduced foraminal height,
caused by the more horizontal orientation of the
foramen, and the associated bulging of the inter-
vertebral disc into the foramen, which compresses
the exiting nerve root against the undersurface of
the pedicle (Fig. 7b).15 Rarely, nerve root com-
pression may be due to an associated disc prolapse
(Fig. 8). With isthmic spondylolisthesis, the spinal
canal is widened and therefore central canal
stenosis is not a feature. The increased AP canal
dimension identified on mid sagittal MRI allows for
the differentiation of isthmic and degenerative
spondylolisthesis to be made with a high degree of
accuracy (Figs. 7a and 8a).16
Type 3, degenerative spondylolisthesis
This is the commonest cause of lumbar spondylo-
listhesis above the age of 50 years. The neural arch
is intact and the slip occurs because of degenera-
tive changes in the facet joints with associated disc
degeneration. These cases show a more sagittal
orientation of the facet joints in the lower lumbar
spine, which is a congenital variation.17 The facet
joints hence tend to transmit the body weight
anteriorly rather than inferiorly. The intervertebral
disc at this level starts to show premature degen-
erative changes. The degree of slip is usually mild,
with a mean slip of 14% reported in a study of 200
patients.18 As the neural arch is intact, even a small
progression in the slip can result in cauda equina
compression. This condition affects the L4/5 level
most commonly (6–9 times more common than at
other levels), is 4 times more common in women
and 3 times more common in persons of African
origin as compared with Caucasians. Its incidence
increases 4 times if there is a sacralized L5.18 The
osteoarthritic changes seen are synovitis, cartilage
degeneration, osteophytes, articular process frac-
tures, osteochondral loose bodies and capsular
The imaging of lumbar spondylolisthesis 539

Figure 9 Lateral radiograph of the lower lumbar spine

shows degenerative L4/5 spondylolisthesis above a
transitional L5 vertebral body. Malalignment of the
spinous processes with anterior slip of the L4 spinous
process relative to L5 allows differentiation from isthmic
spondylolisthesis.

Figure 8 Disc prolapse with isthmic spondylolisthesis. (a)

Sagittal T2W FSE MRI shows L5/S1 isthmic spondylolisthesis
with associated disc prolapse. Note the increased ante-
roposterior canal dimension, which differentiates isthmic
spondylolisthesis from degenerative spondylolisthesis. (b)
Axial T2W FSE MRI shows a left paracentral L5/S1 disc
prolapse with compression of the left S1 nerve root.
540
Figure 10 Degenerative L3/4 spondylolisthesis. (a)
Lateral myelogram demonstrates mild L3/4 spondylo-
listhesis with associated central canal stenosis. (b) Axial
CT myelogram through the L3/4 disc shows advanced
facet osteoarthritis with a sagittal orientation of the
facet joints.
S. Butt, A. Saifuddin
laxity.19 Clinical symptoms include low back pain
and leg pain, resulting from disc and facet
degeneration, lateral recess and foraminal stenosis
leading to nerve root compression. There is a good
correlation between the presence of degenerative
spondylolisthesis and symptoms of low back and leg
pain.20 With worsening disc degeneration and
progressive spondylolisthesis, the symptoms may
change from low back pain to neurogenic claudica-
tion due to central canal stenosis.21
Radiographs show facet osteoarthritis and loss of
disc height. The degree of slip is evident on lateral
radiographs. The frequent rotatory component can
make interpretation difficult. Since the neural arch
is intact, the spinous process moves forward with
the vertebral body. This results in malalignment of
the spinous processes, which can be identified on
lateral radiographs and allows differentiation from
isthmic spondylolisthesis (Fig. 9).
CT shows the alignment of the facet joints and
their degenerative changes. A more sagittal orien-
tation of the facet joints has been shown to be
associated with a greater incidence of degenerative
spondylolisthesis (Fig. 10). In a study by Kim et al.17
sagittal facet angle was less than 338 in subjects
with degenerative spondylolisthesis compared with
438 in a control group. Asymmetrical slip of the
facets results in a rotational component to the
spondylolisthesis. The role of CT and CT myelogra-
phy in the assessment of neurological symptoms in
degenerative spondylolisthesis has been largely
replaced by MRI.
The major advantage of MRI is its ability to
demonstrate narrowing of the central canal, lateral
recesses and neural exit foramina with associated
compression of the cauda equina and exiting nerve
roots (Fig. 11a,b). The facet joint degenerative
changes are shown by the presence of osteophytes
and cartilage loss. Thickening of the ligamentum
flavum adds to central canal and lateral recess
stenosis (Fig. 11b).22 Stenosis in the inferior aspect
of the lateral recess is caused by the ventral slip of
the inferior articular processes. In the case of L4/5
degenerative spondylolisthesis, this results in com-
pression of the L5 nerve roots at the level of the L5
pedicle (Fig. 11c). As a result of the slip, the
intervertebral foramen at the involved level
assumes a more horizontal configuration, resulting
in reduced foraminal height. This, together with
bulging of the degenerate disc into the foramen,
may result in foraminal stenosis. In the case of L4/5
degenerative spondylolisthesis, this can cause L4
root compression.
The presence of facet joint synovial cysts (facet
ganglia), which have a recognized association with
degenerative spondylolisthesis, can also cause
The imaging of lumbar spondylolisthesis 541

Figure 11 (continued )

Figure 11 Degenerative spondylolisthesis and associ-

ated spinal stenosis. (a) Sagittal T2W FSE MRI shows L4/5
spondylolisthesis and central canal stenosis, manifest as
complete loss of cerebrospinal fluid around the cauda
equina. (b) Axial T2W FSE MRI through the L4/5 disc shows
severe central canal stenosis and marked thickening of
the ligamentum flavum. (c) Axial T2W FSE MRI at the L5
pedicle level shows compression of both L5 roots within
the lateral recesses due to the forward slip of the inferior
articular processes.
542 S. Butt, A. Saifuddin

Figure 12 Degenerative L3/4 spondylolisthesis with

associated facet ganglion. (a) Sagittal T2W FSE MRI at the
level of the left lamina shows minor L3/4 degenerative
spondylolisthesis and a small facet ganglion (arrow). (b)
Axial T2W FSE MRI shows the ganglion resulting in lateral
recess stenosis.
The imaging of lumbar spondylolisthesis 543

narrowing of the lateral recesses and are well

shown on MRI (Fig. 12).23
The presence of abnormal segmental motion at
the level of the slip has been investigated with both
dynamic radiography and MRI. Wood et al.24 com-
pared the degree of translation at the level of the
slip on flexion/extension radiographs with subjects
imaged in both erect and lateral decubitus pos-
itions. They found that of 50 cases, 31 displayed
abnormal translation (defined as greater than 8%)
and that of these abnormal translation was evident
in 18 only in the lateral decubitus view. The
spontaneous reduction of lumbar spondylolisthesis
on supine MRI has also been reported (Fig. 13a,b).25
McGregor et al.26 investigated the presence of
segmental motion between flexion and extension in
patients with both isthmic and degenerative spon-
dylolisthesis using an open interventional MRI unit.
However, in a comparison with normal controls,
they were unable to demonstrate any detectable
instability manifest as either abnormal angulation
or translation. The use of axial loaded MRI to
demonstrate occult spinal stenosis has been
described;27 however, the role of axial loading has
not been formally assessed in patients with lumbar
spondylolisthesis (Fig. 13b,c).

Type 4, traumatic spondylolisthesis

Traumatic spondylolisthesis is rare and results from

fractures or dislocations involving any part of the
neural arch except the pars interarticularis, for
example the pedicle or the facet joints. It is almost
always secondary to severe trauma. The slip may
occur gradually over a few weeks or months.28 The
detailed assessment of the fracture is best demon-
strated by CT MPR (Fig. 14a). MRI demonstrates the
associated soft tissue injury, which includes rupture
of the intervertebral disc and posterior ligamentous
complex (Fig. 14b).29

Type 5, pathological spondylolisthesis

Pathological spondylolisthesis can be divided into

two types.
Type a can occur when a generalized bone
Figure 13 Dynamic nature of degenerative lumbar
spondylolisthesis. (a) Erect lateral radiograph of the
lumbosacral junction demonstrates a mild L4/5 degen-
erative spondylolisthesis. (b) Sagittal T2W FSE MRI shows
normal spinal alignment at L4/5. (c) Axial loaded T2W FSE
MRI obtained in a low field open MR unit: the L4/5
spondylolisthesis is now evident, together with the
development of central canal stenosis.
Figure 14 Traumatic L1/2 spondylolisthesis due to
bifacet dislocation. (a) Sagittal CT MPR through the
right facet level demonstrates L1/2 facet dislocation with
fracture through the superior endplate of L1. Note that
the pars interarticularis of L1 is intact (arrow). (b) Fat-
suppressed sagittal T2W FSE MRI shows traumatic L1/2
spondylolisthesis with associated rupture of the L1/2
intervertebral disc and disruption of the posterior
ligamentous complex.
544
Figure 15 Pathological spondylolisthesis due to Paget’s
disease of L5. (a) Midline sagittal T2W FSE MRI shows
typical features of chronic inactive Paget’s disease of L5
with expansion of the vertebral body and Grade 1 L5/S1
spondylolisthesis. (b) Parasagittal T2W FSE MRI through
the pedicle level shows elongation of the L5 pars
interarticularis.
S. Butt, A. Saifuddin
Figure 16 Pathological L4/5 spondylolisthesis due to
diffuse involvement of L4 by haemangioma with patho-
logical fracture through the pars interarticularis.
disease weakens the spine. Examples include
Paget’s disease (Fig. 15), osteoporosis,30 osteogen-
esis imperfecta,31 achondroplasia, arthrogryposis
and osteopetrosis.32
Type b can occur when a focal disease process
weakens the pars interarticularis, resulting in
pathological fracture and spondylolisthesis.
Examples include syphilis,1 TB and neoplastic
processes (Fig. 16).
Type 6, iatrogenic spondylolisthesis
This can follow spinal decompression performed for
spinal stenosis, laminectomy for disc removal, or
any other spine surgery in which it is necessary to
decompress the spinal canal (Fig. 17). After
laminectomy and facetectomy, extensive resection
of the facet joints and neural arch without fusion
allows slippage. Fox et al.33 found a 31% incidence
of spondylolysis after posterior decompression
without fusion. Spondylolysis can also be seen
following posterior spinal fusion. The defects are
usually recognized within 5 years of fusion and in
most cases occur immediately above the fusion
mass.
The imaging of lumbar spondylolisthesis 545

Figure 17 Iatrogenic spondylolisthesis. (a) Lateral radiograph of the lumbar spine demonstrating Paget’s disease of L4
with normal spinal alignment. (b) Anteroposterior radiograph for Paget’s spinal stenosis demonstrates wide posterior
decompression at the L4 and L5 levels. (c) Lateral postoperative radiograph shows the development of L4/5
spondylolisthesis.
546
Conclusions
Spondylolisthesis has a variety of causes. In young
patients, congenital and isthmic varieties are
common. These entities have a genetic back-
ground, and repeated physical trauma also plays a
part in their aetiology. The degenerative variety is
the commonest entity in patients aged over 50
years. The degree of slip is not accurately related to
the symptoms in the dysplastic and isthmic var-
ieties, but is clearly related in the degenerative
variety.
Evidence of nerve root compression on MRI
correlates well with the presence of radiculopathy.
Most cases respond adequately to a conservative
approach and surgery is required in only a minority
of cases.
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