Literature Review

A Review of the Main Classifications of Lumbar Spondylolisthesis

Zhibin Lan1,2, Jiangbo Yan1, Yang Yang1, Qu Xu1, Qunhua Jin1,2

Key words - OBJECTIVE: This study was conducted to review the main classifications and
- Classifications to present author’s recommendations.
- Lumbar spondylolisthesis
- Pseudo-spondylolisthesis - METHODS: Review of English language medical literature.
- Spondylolisthesis
- Type - RESULTS: In recent decades, classification systems of lumbar spondylolis-
Abbreviations and Acronyms
thesis have been proposed based on many factors, from essential causes to
CARDS: Clinical and Radiographic Degenerative combinations of imaging features and clinical manifestations; the latter type of
Spondylolisthesis system is more clinically practical. We have systematically listed the main types
LL: Lumbar lordosis of classification systems in chronological order to make it easier for clinicians
PI: Pelvic incidence
PT: Pelvic tilt
to find the type of diagnosis and treatment suitable for their patients and develop
SL: Segmental lordosis an appropriate treatment plan.
SS: Sacral slope
- CONCLUSIONS: Classification systems for lumbar spondylolisthesis have
SVA: Sagittal vertical axis
been proposed that have been based on the study of the essential causes or the
From the 1Ningxia Medical University, The General Hospital combination of imaging features and clinical manifestations; the latter type of
of Ningxia Medical University, Yinchuan, Ningxia, China; and
2
Orthopedics Ward 3, The General Hospital of Ningxia system is more clinically practical. We still have much work to do in exploring a
Medical University, Yinchuan, Ningxia, China more applicable classification of lumbar spondylolisthesis.
To whom correspondence should be addressed:
Qunhua Jin, Ph.D.
[E-mail: lzb360999@163.com]
Citation: World Neurosurg. (2023) 171:94-102.
https://doi.org/10.1016/j.wneu.2022.12.104 pathologies such as kyphosis, can extension of the column and the increase
Journal homepage: www.journals.elsevier.com/world-
increase the incidence of slippage.3 of the shear force through the same area,
neurosurgery Lumbar spondylolisthesis is divided to maintain lordosis, the stress in the
Available online: www.sciencedirect.com into true spondylolisthesis and pseudo- pars interarticularis will increase
1878-8750/$ - see front matter ª 2022 Elsevier Inc. All
spondylolisthesis. True spondylolisthesis accordingly.14
rights reserved. refers to unilateral or bilateral lumbar In recent decades, different classifica-
isthmus disconnections or pars defects tions of lumbar spondylolisthesis have
due to congenital developmental de- been proposed according to the etiology,
INTRODUCTION formities, trauma fractures, chronic in- imaging parameters and clinical symp-
Lumbar spondylolisthesis refers to the juries, etc., which cause the affected toms. Some classifications focus on true
relative displacement of the upper and vertebra to slide forward once subjected to spondylolisthesis,15 and some focus on
lower vertebrae due to some reasons, most external forces. The heritability of isthmus pseudospondylolisthesis.16-18 Some
of which occurred at L4/5 or L5/S1. Spon- spondylolisthesis is 26%.4 Incidence varies systems are mainly suitable for high-
dylolisthesis occurs in approximately 6% by race: Caucasians are more common grade spondylolisthesis,19 while others
of the general population, with a male to than Blacks. In an Alaskan tribe, the are better suited for low-grade spondylo-
female ratio of 2:1.1 The incidence of incidence is about 50%.5 The most listhesis.15 There are also some types of
lumbar spondylolisthesis in children commonly affected is L5.1,6-11 While in classification systems that focus on
under 6 years of age is 2.6%, and in 1950, Macnab12 described the clinical nonsurgical treatment. This article is the
adults it is 5.4%.1 The term syndrome of intact nerve arches first review to list the major classification
spondylolisthesis comes from the Greek associated with spondylolisthesis, the so- systems of lumbar spondylolisthesis
words spondylos, which means called “pseudospondylolisthesis”. The developed over the past few decades in
“vertebra”, and olisthesis, which means term “degenerative spondylolisthesis” was chronological order. Our purpose is to
“to slide”. This term was first used by coined by Newman13 in 1955, and he help clinicians more easily find a
Kilian in 1854 in Lonstein et al.2 pointed out that vertebral diagnosis and treatment plan suitable for
Activities that maintain the column in spondylolisthesis of the complete nerve their patients and to provide new ideas
bent postures and increase lordosis, such arch was the result of lumbar facet joint for the future to propose a more
as Olympic gymnastics, weightlifting, degenerative arthritis. Biomechanical clinically applicable lumbar
diving, football, and volleyball, and studies have also shown that with the spondylolisthesis classification system.

94 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2022.12.104


ZHIBIN LAN ET AL.
Table 1. Etiological Classification (Wiltse et al.)
Type Description
I Dysplastic In this type congenital abnormalities of the upper sacrum or the arch of L5 permit
the olisthesis to occur
II Isthmic a) Lytic-Fatigue fracture of the pars; b) elongated but intact pars; c) acute fracture.
III Degenerative Due to long standing intersegmental instability
IV Traumatic Due to fractures in other areas of the bony hook than the pars
V Pathological Generalized or localized bone diseases
MEYERDING GRADING SYSTEM not part of the original scoring
The name of Meyerding is familiar to most system.20,21 Although Meyerding was the
spine surgeons because of the Meyerding first person to propose a slipping
classification, this system could not
grading of spondylolisthesis. The classic
distinguish between isthmus and
paper on lumbar spondylolisthesis by
hypoplasia. In addition, the most
Meyerding was published in 1932.20 In the
degenerative lumbar spondylolisthesis is
paper, he described the demographic and
classified as Grade I or II by the
clinical characteristics of 207 patients with
Meyerding grading system, leaving little
spondylolisthesis who appeared at the
room for differentiation. For severe
Mayo Clinic from 1918 to 1931.
spondylolisthesis, this classification
Meyerding defined the slip on X-ray
system cannot be used to accurately
imaging based on the lower vertebra.
guide treatment and predict the
The caudal vertebra is divided into 4
prognosis of the disease.
parts. Grade 1 refers to the translation of
the cranial vertebra by up to 25%, Grade
2 by up to 50%, Grade 3 by up to 75%, WILTSE, NEWMAN, AND MACNAB
and Grade 4 by up to 100%. The CLASSIFICATION SYSTEM
commonly used grade 5, which 22
represents more than 100% slippage, is In the year of 1976, Wiltse et al. classified
lumbar spondylolisthesis into 5 types
(dysplastic, isthmic, degenerative,
traumatic, and pathological) based on
etiology and anatomy, but not
Table 2. MarchettieBartolozzi
morphology (Table 1). This classification
Classification of Spondylolisthesis
system regards degenerative lumbar
Developmental Acquired spondylolisthesis as one subtype and
there is no further subdivision, which
Low dysplastic Traumatic hinders any deeper understanding.
With lysis Acute fracture Moreover, although it contains the
salient features of the disease, it does
With elongation Stress fracture
not guide the treatment and prognostic
High dysplastic Postsurgical prediction of the disease and is,
With lysis Direct therefore, not very practical.
With elongation Indirect
Pathologic MARCHETTIeBARTOLOZZI
Local CLASSIFICATION SYSTEM
Systemic
In 1997, an etiology-based classification
system proposed by Marchetti and Barto-
Degenerative lozzi distinguished between develop-
Primary mental and acquired spondylolisthesis
Secondary (Table 2).23 Developmental
spondylolisthesis is divided into 2 main
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LITERATURE REVIEW
CLASSIFICATIONS OF LUMBAR SPONDYLOLISTHESIS
types (low and high dysplastic),
depending on the risk of further
spondylolisthesis and the severity of bony
dysplastic changes present on the L5 and
S1 vertebrae. Acquired spondylolisthesis
is the result of traumatic, iatrogenic,
pathologic, or degenerative causes.
The term “isthmic” should be avoided
as it is a nonspecific anatomical reference
that does not distinguish between devel-
opmental and acquired forms of spondy-
lolisthesis. Both types may have
interarticular defects, but they represent
significantly different pathological
processes.24
The MarchettieBartolozzi system was
recognized by the Spine/SRS (Scoliosis
Research Society) Spondylolisthesis Sum-
mary Statement (2005) because it high-
lights the pathogenesis of different types
of spinal spondylolisthesis and, is there-
fore, probably the most relevant to natural
history, risk of progression, and thera-
peutic significance.25
However, we have to point out that this
classification system has no quantitative
indicators, and it cannot accurately deter-
mine the degree of adolescent slippage,
disease changes, and surgical treatment
methods.
MAC-THIONG AND LABELLE
CLASSIFICATION SYSTEM
Before Mac-Thiong et al. proposed a new
classification system, some authors per-
formed related research on lumbosacral
sagittal parameters: in low-grade devel-
opmental spondylolisthesis, Roussouly
et al.15 found that high pelvic incidence
(PI) was associated with high sacral slope
(SS) (SS >40
), tending to increase the
shear stress on the L5-S1 intervertebral
disc and causing increased tension on the
L5 articular process; in subjects with lower
PI and SS (SS <40
), when repeated
stretching exercises occur, the articular
facets of L4 and S1 hit L5 and cause lytic
defects. This is the so-called “nutcracker
mechanism”. Through cluster analysis,
Labelle et al.26 further confirmed the
existence of 2 different subgroups of low-
grade developmental spondylolisthesis,
namely, the high PI/high SS group (shear
type) and the low PI/low SS group
(nutcracker type) (Figure 1). To
distinguish among patients with high-
grade spondylolisthesis, Hresko et al.19
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 LITERATURE REVIEW
ZHIBIN LAN ET AL. CLASSIFICATIONS OF LUMBAR SPONDYLOLISTHESIS

sacroiliac-pelvic sagittal balance and

Low-grade spondylolisthesis High-grade spondylolisthesis morphology. The 8 types of lumbar
spondylolisthesis are described below: 1)
degree of spondylolisthesis (low and
high), 2) degree of dysplasia (low and
high), and 3) sagittal sacrum-pelvic bal-
ance. The classifications are organized
into groups and subgroups with
increasing severity according to a pro-
gressive algorithm, and the complexity of
the surgery is proportional to the severity
of the spinal spondylolisthesis (Table 3,
Figure 2).
High PI / high SS High PI / low SS High SS / low PT Low SS / High PT However, subsequent research by Mac-
（shear type） （nutcracker type） （balanced pelvis） （retroverted pelvis thiong et al.28 found that the
Figure 1. For low-grade spondylolisthesis, the sagittal spinopelvic interobserver reliability was not very
balance can be classified as high pelvic incidence (PI)/high sacral slope high, because this classification was
(SS) (shear type) or low PI/low SS (nutcracker type). For high-grade difficult to determine the degree of
spondylolisthesis, it can be classified as high SS/low pelvic tilt (PT)
(balanced pelvis) or low SS/high PT (retroverted pelvis). PL, pelvic
dysplastic lumbar spondylolisthesis on
incidence; SS, sacral slope; PT, pelvic tilt. imaging data (kappa: 0.43).

also used cluster analysis to classify 2
patient subsets: patients with a relatively
balanced sacrum/pelvis (high SS/low
pelvic tilt [PT]) and patients with an
unbalanced sacrum/pelvis and significant
lumbosacral kyphosis, such as
a retroverted pelvis/vertical sacrum (low
SS/high PT) (Figure 1).
Soon, in 2006, Mac-thiong et al.27
proposed a new classification of L5/S1 to
guide the surgical treatment of slippage
in children and adolescents. The
classification not only clarifies the
concepts of low and high dysplasia
proposed by MarchettieBartolozzi et al.,
and combines the latest knowledge of
CLASSIFICATION SYSTEM PROPOSED BY
THE SPINAL DEFORMITY STUDY GROUP
Based on the research by Mac-thiong
et al., in 2011, the Spinal Deformity
Study Group improved the classification
method by excluding the evaluation stan-
dard of dysplastic lumbar spondylolis-
thesis and proposing a new classification

Table 3. Surgical Classification of L5-S1 Spondylolisthesis in Children and Adolescentsz

Grade of slip* Degree of dysplasiay Sagittal Spinopelvic Balance Suggested Treatment

Low-grade (0,1, or 2)
High-grade (3 or 4)
Spondyloptosis
Low dysplastic Low PI/low SS (nutcracker type)
High PI/high SS (shear type)
High dysplastic Low PI/low SS (nutcracker type)
High PI/high SS (shear type)
Low-dysplastic High SS/low PT (balanced pelvis)
Low SS/high PT (retroverted pelvis)
High-dysplastic High SS/low PT (balanced pelvis)
Low SS/high PT (retroverted pelvis)
High-dysplastic
Pars repair (grade 0 or 1) versus in situ L5-S1
PLF  instrumentation  reduction for grade 2y
In situ L5-S1 PLF  instrumentation  reduction for grade 2y
In situ L5-S1 PLF and instrumentation  reduction for grade 2y
In situ L5-S1 PLF and instrumentation  L4 and pelvic fixation  reduction for
grade 2y
In situ L4-S1 PLF and instrumentation  pelvic fixation  partial reductiony
Partial reduction and L4-S1-pelvic instrumentation and PLF  L5-S1 IF
Partial reduction and L4-S1-pelvic instrumentation and PLF  L5-S1 IF
Partial reduction and L4-S1-pelvic instrumentation and PLF and L5-S1 IF
Circumferential fusion, instrumentation, with or without reduction

PLF, posterolateral fusion; PI, pelvic incidence; SS, sacral slope; PT, pelvic tilt; SDSG, Spinal Deformity Study Group; IF, interbody fusion; ALIF, Anterior lumbar interbody fusion; TLIF, trans-
foraminal lumbar interbody fusion; PLIF, Posterior lumbar interbody fusion.
IF using ALIF, TLIF or PLIF technique.
*According to Meyerding classification.
yCorrection of lumbosacral kyphosis should be given a strong consideration when slip angle >10
, lumbosacral angle of Dubousset < 100
or SDSG lumbosacral angle 15
.
zData from Mac-Thiong et al., 2006.

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ZHIBIN LAN ET AL.
Slip angle SDSG lumbosacral angle
Lumbosacral angle
Figure 2. The lumbosacral angle of Dubousset is defined as the angle formed by the upper endplate of
L5 and a line drawn along the back of the S1 vertebra; the slip angle is defined as the angle formed by
the lower end plate of L5 and a line perpendicular to the back of S1 vertebra; and the lumbosacral
angle described by the Spinal Deformity Study Group is defined as the angle formed by the end plate
on the L5 and the end plate on the S1. SDSG, Spinal Deformity Study Group.
of L5/S1 spondylolisthesis (6 types) further intervertebral fusion is needed to
(Figure 3).29 prevent the progression of
This classification is based on the spondylolisthesis, but the sagittal balance
spinal-pelvic sagittal parameters of pa- cannot be maintained without resetting
tients with lumbar spondylolisthesis, the spondylolisthesis. Regarding the
which reflects the severity and prognosis question of whether high-grade lumbar
of the spondylolisthesis. As the degree of spondylolisthesis needs to be reduced, this
the spondylolisthesis increases, the classification method suggests that it
complexity of the operation increases. mainly depends on whether the normal
This classification method emphasizes the spine-pelvic sagittal balance can be main-
diversity of L5/S1 spondylolisthesis posture tained after surgery.29 Type 4 lumbar
compensation. spondylolisthesis does not require forcible
For patients with type 1 and type 2 lumbar reduction of the spondylolisthesis.
spondylolisthesis, because the probability Posterior intervertebral fusion fixation
of spondylolisthesis is relatively small, only surgery is sufficient to maintain the
fixed decompression can obtain a good normal sagittal plane sequence. For type 5
therapeutic effect. A recent study also sup- lumbar spondylolisthesis, reduction and
ports this view and further states that fusion parallel fixation and fusion are preferred.
is needed only for patients with slippery If the reduction is difficult, in situ fixation
segment instability.30 Type 3 lumbar and fusion can also be performed, which
spondylolisthesis is more progressive. On can also maintain spinal sagittal plane
the basis of decompression and fixation, stability. Due to the severe imbalance of
Type 1: PI<45° (nutcracker)
Low grade Type 2: PI 45 to 60°
Type 3: PI>60°
L5-S1 spondy
Type 4: Balanced Pelvis
High grade Type 5: Balanced Spine
Retroverted Pelvis
Type 6: Unbalanced spine
Figure 3. Spinal Deformity Study Group L5-S1 spondylolisthesis
classification. Data from Labelle et al., 2011. SDSG, Spinal Deformity
Study Group.
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LITERATURE REVIEW
CLASSIFICATIONS OF LUMBAR SPONDYLOLISTHESIS
the sagittal plane in patients with type 6
lumbar spondylolisthesis, vertebral body
fusion and internal fixation surgery must
be performed to restore and maintain the
normal sagittal plane sequence of the
spine.
However, according to the guidelines
for treatment of lumbar spondylolis-
thesis,31 although the recovery of sagittal
plane balance is obviously related to the
improvement of symptoms after
spondylolisthesis, the ideal value of
spinal-pelvic sagittal parameters has not
been determined and further research is
needed.
CLASSIFICATION PROPOSED BY THE
FRENCH SOCIETY FOR SPINE SURGERY
In 2013, Gille et al.16 reported a round
table discussion held by the French
Society for Spine Surgery to propose a
classification system for degenerative
spondylolisthesis. This classification
system divides degenerative lumbar
spondylolisthesis into 5 categories and
evaluates the results of various surgical
options (Table 4).
The recommended treatment options
are as follows:
 In type 1 spondylolisthesis, it is not
necessary to restore segmental lordosis
(SL), so a simple posterior fusion
without an interbody cage seems
appropriate. The best option for elderly
type 1 patients may be simple decom-
pression without fusion. Finally, dy-
namic stabilization may be best suited
for type 1 slippage.
 Type 2 spondylolisthesis requires SL to
recover at the slippage site. In healthy
individuals, L4-S1 lordosis accounts for
two thirds of the total number of lumbar
lordosis (LL) cases. In such cases,
interbody cages can be very useful, as
studies have shown that anterior sup-
port can help correct local kyphosis and
limit the risk of postoperative
complications.
 In type 3 spondylolisthesis, in which low
LL is well corrected on a dynamic view,
short assembly may be appropriate.
When LL correction is inadequate, sur-
gical treatment is the same as for type 4
spondylolisthesis.
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 LITERATURE REVIEW
ZHIBIN LAN ET AL. CLASSIFICATIONS OF LUMBAR SPONDYLOLISTHESIS

internal fixation and fusion; and patients

Table 4. A New Classification System Proposed by the French Society for Spine with type D should use an interbody
Surgery fusion cage for anterior column fusion,
Characteristics reestablish the support of the anterior
vertebral column, and restore LL.18
Type 1 Preserved segmental lordosis (>5
) and preserved LL (LL > PI-10
) The advantage of this classification is
Type 2 Decreased segmental lordosis (<5
) and preserved LL (LL > PI-10
) that the acquired imaging parameters are
easily obtained from X-ray films, and the
Type 3 Decreased LL (LL < PI-10
)
clinical symptom parameters are also
Type 4 Decreased LL (LL < PI < 10
) with compensation to maintain sagittal balance (PT > 25
) easier to obtain. The clinical application of
Type 5 Sagittal unbalance (SVA >4 cm, with the SVA defined as the distance between the plumb the CARDS classification system is more
line from the center of the C7 body to the anterior margin of S1 plate) credible than the application of the other
available systems, and it has also been
LL, lumbar lordosis; PI, pelvic incidence; PT, pelvic tilt; SVA, sagittal vertical axis.
shown to have high inter- and intra-
observer reliability.

 In type 4 spondylolisthesis, LL repair is parameters measured on the standing

mandatory and requires an extended
structure, usually from L3 to S1.
 In type 5 spondylolisthesis, the treat-
ment of spondylolisthesis is the second
method of correcting sagittal deformity.
This classification system may take
longer than the clinical and imaging
classification systems. Moreover, this
classification system may have the disad-
vantages of necessitating tedious mea-
surements, only addressing single-stage
slippage, and lacking information about
combinations of clinical symptoms.
CLINICAL AND RADIOGRAPHIC
DEGENERATIVE SPONDYLOLISTHESIS
CLASSIFICATION
In 2015, Kepler et al.17 proposed a clinical
and radiographic degenerative
spondylolisthesis (CARDS) classification
based on 3 imaging parameters and 1
clinical symptom parameter. The imaging
Morphology
subgroups
Modifier 0 ：without leg pain (absent)
Leg pain
Modifier 1 ：with unilateral leg pain
modifier
Modifier 2 ：with bilateral leg pain
Figure 4. Clinical and radiographic degenerative spondylolisthesis
classification. CARDS, clinical and radiographic degenerative
spondylolisthesis.
lateral X-ray film, and the lumbar spine
flexion and extension lateral X-ray films
were the intervertebral space height,
segmental angle, and vertebral
translation. The intervertebral space
height refers to the distance between the
lower endplate of the upper vertebra and
the upper endplate of the lower vertebra;
the segmental angle refers to the angle
between the lower endplate of the upper
vertebral body and the extension line of
the upper endplate of the lower vertebral
body; and vertebral translation is defined
as before (Figure 4). As shown in the
figure, there are 12 subtypes of CARDS,
namely, A0, A1, A2, B0, B1, B2, C0, C1,
C2, D0, D1, and D2.
The recommended treatment options
are as follows: For patients with type A, A0
can be treated conservatively, and types A1
and A2 can be treated with simple
decompression; type B patients choose
conservative treatment according to their
specific clinical symptoms; patients with
type C are advised to use a combination of
Type A: advanced disc space collapse without kyphosis
Type B: disc partially preserved with translation of 5 mm or less
Type C: disc partially preserved with translation of more than 5mm
Type D: kyphotic alignment
CLASSIFICATION SYSTEM PROPOSED BY
GILLE ET AL
In 2017, Gille et al.18,32 proposed a
classification method based on lateral X-
ray imaging parameters (EOS system,
EOS imaging, Paris, France) for
degenerative lumbar spondylolisthesis.
The main sagittal parameters measured
are as follows: SL, L1-S1 LL, PI, PT, and
sagittal vertical axis. There are 3 types in
this classification, and the severity in-
creases in order. The classification
method and treatment recommendations
are shown in the Table 5.
A study conducted by Ghailane et al.33
found that this classification system
shows excellent interobserver and
intraobserver reliability, and this simple
method may be an additional sagittal
balance tool that helps surgeons improve
their preoperative analysis of
degenerative lumbar spondylolisthesis.
AUTHORS’ OPINIONS
In recent decades, classification systems
for lumbar spondylolisthesis have been
proposed that range from descriptive to
practical and from simple etiology classi-
fication systems to systems combining
imaging and clinical symptoms.
We believe that the purpose of classifi-
cation of lumbar spondylolisthesis is best
to serve the clinical purpose, so we
recommend CARDS classification. How-
ever, in this classification, the presence of
leg pain alone as a modified factor may be
not comprehensive enough. Therefore, on
this basis, our team modified the classifi-
cation based on years of clinical experi-
ence. Clinical symptoms were used as

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 LITERATURE REVIEW
ZHIBIN LAN ET AL. CLASSIFICATIONS OF LUMBAR SPONDYLOLISTHESIS

vertical orientation of the L5-S1 disc, early

Table 5. A Classification Based on X-Ray Imaging Parameters for Degenerative Lumbar onset of symptoms, and female
Spondylolisthesis sex.9,10,38-41 It was also observed that
Type Sub-Type Description Treatment patients with spondylolisthesis caused by
dysplasia are more likely to progress than
Type 1 1A PI-LL <10
, preserved SL A segmental approach is advised: decompression those with spondylolitic
and fusion alone with no correction or dynamic spondylolisthesis.42
stabilization Changes in spinal stress lines that lead
1B PI-LL <10
, altered SL, preserved LL It is preferable to restore SL using an to further changes in sagittal alignment of
intersomatic device, through an anterior or the spine have been shown to be associated
posterior approach. with the development and progression of
Type 2 2A PI-LL >10
, PT < 25
There is PI-LL mismatch, The aim is to restore a degenerative lumbar spondylolisthesis.43


harmonious spine with a LL adapted to PI. Once degenerative lumbar spine slippage
2B PI-LL >10 , PT > 25
develops, postural compensation may
Type 3 3 SVA >40 mm More aggressive surgical treatment may be induce further changes in the sagittal
considered to correct sagittal malalignment balance parameters of the spinal pelvis,
especially in case of significant clinical sagittal thereby potentially exacerbating
imbalance
slippage.43 Barrey et al.44 suggested that
LL, lumbar lordosis; PI, pelvic incidence; SL, segmental lordosis; SVA, sagittal vertical axis. an increase in L5 endplate tilt angle from
normal reference values predicted spinal
slippage, while an increase in PI predicted
degenerative spondylolisthesis. In the case
modified factors. Modifier 0: no back than in the fusion group. For the selection
of sagittal misalignment, compensation to
pain, leg pain or nerve damage; Modifier of treatment options for lumbar spondy-
maintain upright posture, such as
1: mild lower back pain, leg pain, or nerve lolisthesis, it is necessary to evaluate the
posterior PT, chest flattening, hip
damage; and Modifier 2: severe lower back factors for further progression of spondy-
extension, knee flexion, and ankle flexion,
pain, leg pain, or nerve damage (Figure 5). lolisthesis. Because Matsunaga et al.35,36
may be used to maintain better postural
In the modified classification, we sug- found in a natural history study that
stability. These compensatory
gest the following: Modifier 0: A0, B0, C0, degenerative lumbar spondylolisthesis
mechanisms may correct sagittal spinal-
and D0 should be followed up for obser- patients with a collapsed intervertebral
pelvic instability and lead to better
vation. If further slippage occurs in C0 and disc space often did not experience slip
postural stability with increased PT.45
D0 leading to aggravation of symptoms, progression during 10e18 years of
During lumbar surgery, Oikonomidis
surgical treatment should be considered. follow-up. Dubousset found that a
et al.46 found that correction of rotation
Modifier 1: A1, conservative treatment was lumbosacral angle of less than 100

was significantly associated with clinical
considered. B1, in close consultation with (normal: 90e110
) is the cause of the
outcomes. When the extent of
patients, conservative treatment, or sur- progression of spondylolisthesis.37
intraoperative decompression is
gery is an option. C1, D1, surgical treat- Patients with low PI and low SS
sufficient, complete reduction of
ment may be recommended. Modifier 2: (“nutcracker” mechanism) have a lower
spondylolisthesis is not necessary. It is
we recommend surgical treatment. risk of progression. Dysplasia and high-
more important to correct rotation and
For mild lumbar spondylolisthesis, grade spondylolisthesis (>50%) may be
restore the physiological curvature of the
decompression alone or fusion? The latest important factors in the progression of
lumbar spine.
study was conducted by Austevoll et al.34 lumbar spondylolisthesis. Other factors
We examined previous reviews that
showed that revision rates were slightly that contribute to the progression of
compared the outcomes of surgical
higher in the decompression-alone group spondylolisthesis are increased slip angle,
treatment for lumbar spondylolisthesis
with the outcomes of simple decom-
pression and internal fixation (Table 6).
Type A: advanced disc space collapse without kyphosis There is no clear evidence as to which
Type B: disc partially preserved with translation of 5 mm or less surgical approach has the best outcome.
Morphology
subgroups Type C: disc partially preserved with translation of more than 5mm
The clinical efficacy and risk of
recurrence of each strategy in the short-
Type D: kyphotic alignment
and long-term remain unclear. This re-
Modifier 0 ：no back pain, leg pain and nerve damage view was also limited by the lack of ran-
Symptom
Modifier 1 ：mild lower back pain or leg pain, or nerve damage
domized controlled trials and the
modifier
Modifier 2 ：severe lower back pain or leg pain, or nerve damage
relatively low level of evidence among the
included studies.
Figure 5. Modified Clinical and radiographic degenerative Although spondylolisthesis usually oc-
spondylolisthesis (mCARDS) classification. CARDS, clinical and
curs in the lumbar spine, subsequent
radiographic degenerative spondylolisthesis.
compensatory changes to the spine

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 LITERATURE REVIEW
ZHIBIN LAN ET AL. CLASSIFICATIONS OF LUMBAR SPONDYLOLISTHESIS

Table 6. Summary of Systematic Review and Findings

Evidence
Author Title Country Source Title Level* Main Outcomes/Conclusions

Liang et al. Decompression plus fusion versus decompression alone
(2017) for degenerative lumbar spondylolisthesis: a systematic
review and meta-analysis
Shen et al. Effectiveness and safety of decompression alone versus
(2022) decompression plus fusion for lumbar spinal stenosis
with degenerative spondylolisthesis: a systematic review
and meta-analysis
Ramhmdani Iatrogenic Spondylolisthesis Following Open Lumbar
et al. (2018) Laminectomy: Case Series and Review of the Literature
Andrei et al. Is There a Role for Decompression Alone for Treating
(2015) Symptomatic Degenerative Lumbar Spondylolisthesis? A
Systematic Review
Steiger Surgery in lumbar degenerative spondylolisthesis: Switzerland Eur Spine J
et al. (2014) indications, outcomes and complications. A systematic
review
China Eur Spine J C Based on the available evidence, decompression plus
fusion maybe be better than decompression alone in the
treatment of degenerative spondylolisthesis. Fusion had
advantages of improvement of clinical satisfaction, as
well as reduction of postoperative leg pain, with similar
complication rate to decompression alone.
China Annals of C In patients with lumbar spinal stenosis with degenerative
Translational spondylolisthesis, the effectiveness and safety of
Medicine decompression alone may be superior to decompression
plus fusion in terms of complication rate, operative time,
and the amount of bleeding. However, more high-quality
literature is needed in the future to confirm the best
treatment choice for patients with lumbar spinal stenosis
with degenerative spondylolisthesis.
USA World D In patients without overt preexisting instability,
Neurosurgery laminectomy for lumbar stenosis can disrupt spinal
stability and result in iatrogenic spondylolisthesis. The
extent of decompression of the facet joints, number of
levels decompressed, and preoperative disc space height
can help assess the risk of postoperative
spondylolisthesis. Patients who develop recurrent
radiculopathy after decompressive lumbar laminectomy
should be evaluated for potential iatrogenic
spondylolisthesis.
Brazil Clinical Spine D Satisfactory clinical outcome can be achieved with an
Surgery isolated decompression in selected patients, avoiding the
additional risks and costs of instrumentation and spinal
fusion. Noninstrumented fusion is also an interesting
alternative to instrumented fusion for well-selected
patients to decrease complications related to
instrumentation.
C Despite there being many articles describing and/or
comparing different surgical options for lumbar
degenerative spondylolisthesis, there was insufficient
evidence to draw conclusions concerning clear
indications for specific types of surgical treatment,
predictors of outcome, or complication rates. There
remains a need to establish a decision-making tool to
facilitate daily clinical practice and to assure appropriate
treatment for patients with lumbar degenerative
spondylolisthesis.

A, consistent level 1 studies; B, consistent level 2 or 3 studies or extrapolations from level 1 studies; C, level 4 studies or extrapolations from level 2 or 3 studies; D, level 5 evidence or
troublingly inconsistent or inconclusive studies of any level.
*Oxford Centre for Evidence-Based Medicine-levels of evidence (March 2009). http://www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/.

cannot be ignored. The integrity of the
spine needs to be considered from the
following 4 aspects: stability, balance,
function, and morphology. While the
surgeon is treating lumbar spondylolis-
thesis, it is necessary to consider the
treatment plan based on the integrity of
the spine. Global spinal parameter
indicators may be included in future
slippage classifications.
Although our group proposed an
improved classification based on clinical
experience, no credible and reproducible
studies were conducted. It also does not
take into account indicators of spine
integrity. We still have a lot of work to do.
CONCLUSIONS
In recent decades, classification systems
for lumbar spondylolisthesis have been
proposed that have been based on the
study of the essential causes or the com-
bination of imaging features and clinical
manifestations; the latter type of system is
more clinically practical. We still have

100 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2022.12.104


ZHIBIN LAN ET AL.
much work to do in exploring a more
applicable classification of lumbar
spondylolisthesis.
ACKNOWLEDGMENT
We are grateful to all study participants for
their participation in the study.
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