The L3 Flexion Angle Predicts Failure of Non-Operative Management in Patients with Tandem Spondylolithesis

Study Design: Retrospective cohort study. Objective: Determine impact of standard/novel spinopelvic parameters on global sagittal imbalance, health-related quality of life (HRQoL) scores, and clinical outcomes in patients with multi-level, tandem degenerative spondylolisthesis (TDS). Methods: Single institution analysis; 49 patients with TDS. Demographics, PROMIS and ODI scores collected. Radiographic measurements—sagittal vertical axis (SVA), pelvic incidence (PI), lumbar lordosis (LL), PI-LL mismatch, sagittal L3 flexion angle (L3FA) and L3 sagittal distance (L3SD). Stepwise linear multivariate regression performed using full length cassettes to identify demographic and radiographic factors predictive of aberrant SVA (≥5 cm). Receiver operative curve (ROC) analysis used to identify cutoffs for lumbar radiographic values independently predictive of SVA ≥5 cm. Univariate comparisons of patient demographics, (HRQoL) scores and surgical indication were performed around this cutoff using two-way Student’s t-tests and Fisher’s exact test for continuous and categorical variables, respectively. Results: Patients with increased L3FA had worse ODI (P =.006) and increased rate of failing non-operative management (P =.02). L3FA (OR 1.4, 95% CI) independently predicted of SVA ≥5 cm (sensitivity and specifity of 93% and 92%). Patients with SVA ≥5 cm had lower LL (48.7 ± 19.5 vs 63.3 ± 6.9 mm, P <.021), higher L3SD (49.3 ± 12.9 vs 28.8 ± 9.2, P <.001) and L3FA (11.6 ± 7.9 vs −3.2 ± 6.1, P <.001) compared to patients with SVA ≤5 cm. Conclusions: Increased flexion of L3, which is easily measured by the novel lumbar parameter L3FA, predicts global sagittal imbalance in TDS patients. Increased L3FA is associated with worse performance on ODI, and failure of non-operative management in patients with TDS.