Causes of Retrolisthesis
Retrolisthesis develops primarily as a compensatory mechanism for sagittal spinal imbalance and is associated with specific spinopelvic parameters, disc instability from degeneration, and thoracolumbar kyphosis. 1
Primary Causative Factors
Sagittal Balance Compensation
- Retrolisthesis serves as an important compensatory mechanism to regulate sagittal balance in the aging spine, particularly in patients with low pelvic incidence (PI), low sacral slope (SS), and reduced lumbar lordosis (LL). 1
- Patients with retrolisthesis demonstrate significantly lower sagittal vertical axis (SVA), PI, SS, and LL compared to those with anterolisthesis or normal alignment. 1
- Increased thoracolumbar kyphosis (TLK) is significantly associated with retrolisthesis development, representing the spine's attempt to maintain overall sagittal alignment. 1
Disc Degeneration and Instability
- Disc instability due to degeneration contributes to the development and progression of retrolisthesis, though the disks at levels with retrolisthesis are typically not severely degenerated (average Pfirrmann score of 2.11). 1
- Degenerative disc disease at the L4-5 level and higher slip angles are consistent findings in patients who develop retrolisthesis at the level above a spondylolytic spondylolisthesis. 2
- A cascade of degenerative changes involving both disc and facet joints occurs at levels above a spondylolytic spondylolisthesis, predisposing to retrolisthesis formation. 2
Secondary Contributing Factors
Adjacent Segment Degeneration
- Retrolisthesis commonly develops at the motion segment immediately above a lower-level spondylolytic spondylolisthesis (29% incidence at L4-5 above L5-S1 slip). 2
- The abnormal motion caused by a lower-level spondylolisthesis predisposes adjacent segments to degenerative changes that can manifest as retrolisthesis. 2
Biomechanical Characteristics
- Low pelvic incidence appears to be a predisposing anatomical factor for retrolisthesis development. 1
- The combination of reduced lumbar lordosis and thoracolumbar kyphosis creates biomechanical conditions favoring posterior vertebral subluxation. 1
Traumatic Causes (Rare)
- Traumatic retrolisthesis is a rare injury mechanism that can result from high-energy trauma such as falls from significant heights, potentially causing acute disc extrusion and nerve root injury. 3
- These traumatic cases represent highly unstable injuries requiring surgical decompression and stabilization. 3
Important Clinical Caveats
- The prevalence of retrolisthesis does not vary significantly by sex, age, race, smoking status, or education level in patients with disc herniation. 4
- Retrolisthesis alone is not associated with increased incidence of degenerative disc disease, posterior degenerative changes, or vertebral endplate changes when these conditions are assessed independently. 4
- The presence of retrolisthesis becomes clinically more evident after removal of a disc herniation, suggesting that symptoms from disc pathology may initially overshadow the contribution of retrolisthesis to pain and dysfunction. 5