Objective: Adjacent segment retrolisthesis is a common yet frequently overlooked complication after lumbar fusion, which may lead to reoperation. However, its risk factors, particularly those related to preoperative degenerative status and intraoperative variables, remain poorly understood. Therefore, this study aimed to elucidate the risk factors that contribute to the development of retrolisthesis in the adjacent segment following transforaminal lumbar interbody fusion (TLIF).
Methods: We retrospectively reviewed 473 patients who underwent lower lumbar fusion for degenerative diseases from June 2017 to September 2022, with a minimum follow-up of 2 years. Seventy patients who developed radiographic retrolisthesis postoperatively were included in the RR group, and 18 patients with symptoms were classified into the symptomatic retrolisthesis (SR) group. Using a 1:2 ratio, 140 patients without retrolisthesis were matched as the non-retrolisthesis (NR) group. Preoperative MRI was used to assess fat infiltration and cross-sectional area of the erector spinae, multifidus, and psoas muscles, as well as total endplate score and disc degeneration. CT was used to evaluate facet degeneration and pedicle screw-related facet joint violation. Independent sample t-tests and chi-square tests were used for group comparisons, and multivariate logistic regression analysis was performed to identify independent risk factors.
Results: Baseline age, sex, and bone mineral density were comparable between groups. Multivariate analysis showed that higher preoperative total endplate score (OR 2.086, 95% CI 1.496–2.907, p < 0.001), greater paraspinal muscle fat infiltration (OR 1.117, 95% CI 1.046–1.192, p = 0.001), facet degeneration (OR 2.838, 95% CI 1.762–4.570, p < 0.001), and postoperative facet violation (OR 1.911, 95% CI 1.330–2.746, p = 0.001) were independent risk factors for RR. Predictors of SR included total endplate score (OR 3.506, p = 0.002), fat infiltration of paraspinal muscles (OR 1.230, p = 0.008), facet degeneration (OR 8.940, p = 0.002), and postoperative facet violation (OR 2.873, p = 0.024).
Conclusion: Preoperative degeneration of adjacent endplates, facet joints, and paraspinal muscles, together with postoperative facet joint violation, appears to be significantly associated with the development of retrolisthesis. Patients with retrolisthesis often present with persistent or severe low back pain after lumbar fusion, resulting in impaired quality of life.
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2026 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.
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