Is it possible to predict which spondy patients are more likely to have slower than expected postop recovery?
A new Hospital for Special Surgery (HSS) and Weill Cornell study provides evidence that a high pelvic tilt or depression can, indeed, predict recovery rates from surgical treatment of lumbar spondylolisthesis.
The study, “Clinical and Radiologic Predictors of Slower Improvement and Nonimprovement After Surgical Treatment of L4-L5 Degenerative Spondylolisthesis: Preliminary Results,” appears in the February 1, 2025, edition of Spine.
“We know that some patients do very well after surgery for these diagnoses where other patients take longer to improve or fail to improve,” said co-author Sravisht Iyer, M.D., a spine surgeon at HSS. “We wanted to think more specifically about these conditions.”
Methodology and Results
The HSS team enrolled 233 patients who had been treated with minimally invasive decompression or fusion for L4-5 degenerative lumbar spondylolisthesis and had a minimum of 1-year follow-up.
The team then measured minimal clinically important difference, patient acceptable symptom state, and the global rating change. They also collected data for age, gender, body mass index, surgery type, comorbidities, anxiety, depression, smoking, osteoporosis, and preoperative patient-reported outcome measures. Finally, the team also looked at radiologic variables; specifically, slip percentage, translational and angular motion, facet diastasis/cyst/orientation, laterolisthesis, disc height, scoliosis, main and fractional curve Cobb angles, and spinopelvic parameters.
At less than three months, the team found a correlation between high pelvic tilt and depression and minimal clinically important difference nonachievement and global rating change nonimprovement, respectively. The authors noted that because neither variable retained significance past six months, they were identified as predictors of slower improvement.
Past six months, low preoperative Visual Analog Scale (leg) and high facet orientation were predictors of minimal clinically important difference nonachievement, high L4-5 slip percentage and L5-S1 angular motion were predictors of global rating change nonimprovement, and high preoperative Oswestry Disability Index was a predictor of patient acceptable symptom state nonachievement.
Co-Chief Emeritus of the spine service at HSS, Harvinder Sandhu, M.D., told OTW, “Historically, depression is associated with poorer coping skills and is consequently correlated with slower outcomes from many types of surgical interventions including hip and knee replacements. The results in our study are typical.”
“High pelvic tilt usually requires higher segmental lordosis at L4-5, and this may be more difficult to achieve during correction. This study confirms the presumption that there is variability in the speed of recovery after surgical treatment of degenerative lumbar spondylolisthesis—surgeons should accordingly preoperatively advise patients of this, particularly those with risk factors.”
Discussion
When OTW asked why there are limited data on clinical and radiologic predictors of slower and nonimprovement following surgery for L4-5 degenerative lumbar spondylolisthesis, Dr. Iyer said, “There is a tremendous variability in the presentation of degenerative spondylolisthesis. Despite this, however, the diagnosis of spondylolisthesis is frequently treated as monolithic in the literature. We wanted to delineate factors that might inform how patients do after surgery for this diagnosis.”
“For any surgery, there are a variety of factors that influence patient-related outcomes,” added Dr. Iyer. “We hope this work helps surgeons be more specific in counseling patients undergoing this surgery.”

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