THE INFLUENCE OF PREGNANCY ON

THE DEVELOPMENT OF
DEGENERATIVE SPONDYLOLISTHESIS
PAUL L. SANDERSON,

ROBERT D. FRASER

From the Royal Adelaide Hospital, South Australia

egenerative spondylolisthesis is most common at

the L4/L5 level and in women. There are several
possible reasons for its predilection at this site, but
there is no satisfactory explanation for the
predominance in women. We considered that
pregnancy was a possible inuence.
We reviewed the records and radiographs of 949
women and 120 men aged 50 years and over who had
attended a spinal surgeon for low back pain over a
ve-year period. We found that women who had
borne children had a signicantly higher incidence of
degenerative spondylolisthesis than nulliparous women
(28% v 16.7%; p = 0.043). The men had a 7.5%
incidence, signicantly less than nulliparous women
(p = 0.031). Our results suggest that pregnancy is an
important factor in the aetiology of degenerative
spondylolisthesis.

J Bone Joint Surg [Br] 1996;78-B:951-4.

Received 13 May 1996; Accepted after revision 24 July 1996

Spondylolisthesis with a forward slip of one vertebra on the

next with no break in the neural arch was described by
Macnab (1950). Newman and Stone (1963) pointed out that
there were various causes for slipping with an intact arch
and rst used the term degenerative spondylolisthesis.
Degenerative changes within the facet joints are partly
responsible for allowing forward slip (Spengler 1987), but
Farfan (1980) has shown that there is also a rotatory
component. The condition is four times more common in
women than in men, and six times more common at L4/L5
than at L3/L4, which is the next most affected level. It is
rarely diagnosed before 40 years of age (Rosenberg 1975).
The reasons advanced for its location at the L4/L5 level

P. L. Sanderson, FRCS Ed(Orth), Clinical Spinal Fellow

R. D. Fraser, MD, FRACS, Clinical Professor and Head of Spinal Unit
Level 4, The Bice Building, Royal Adelaide Hospital, North Terrace,
Adelaide, South Australia 5000.
Correspondence should be sent to Professor R. D. Fraser.
1996 British Editorial Society of Bone and Joint Surgery
0301-620XX/96/61291 $2.00
VOL. 78-B, NO. 6, NOVEMBER 1996

include the more sagittal orientation of the L4/L5 facet

joints in relation to the coronal placement of the L5/S1
joints (Grobler et al 1993) and the stability of the fth
lumbar vertebra which is provided by large transverse
processes supported by strong ligaments and muscle attachments (Fitzgerald and Newman 1976). Another factor may
be that a hypermobile L4/L5 level is associated with a lowlying iliac crest; Farfan (1980) considers that in this group
of patients there is more rotational and sheer stress at this
level.
No explanation has been provided for the four times
greater incidence in women, but we gained the clinical
impression that it was seen less often in nulliparous women
and therefore decided to investigate the possible association
with pregnancy.

PATIENTS AND METHODS

We made a random selection from our data base of female
patients with low back pain who attended a spinal surgeons practice from 1990 to 1995. Each had completed a
questionnaire which included information on the number of
children which they had borne. Their plain radiographs of
the lumbosacral spine were examined by the senior author
(RDF) for evidence of degenerative spondylolisthesis. The
level and the percentage slip (5% to 25%) were recorded.
Patients with an isthmic spondylolysis and those who had
had previous lumbar surgery were excluded. A control
group of radiographs of 120 men with low back pain, in the
same age range, was also assessed. Statistical analysis used
the chi-squared test.

RESULTS
Of the 949 women assessed, 96 were nulliparous and 853
had had one or more children. The men in the control group
also had back pain and were well matched for age (Table I).
The levels affected by degenerative spondylolisthesis are

Table I. The number and mean ( SD)

age in years of the patient groups
Group
Nulliparous

Number

Age

96

61.2 6.4

Parous

853

63.1 5.1

Men

120

64.1 5.8
951

952

P. L. SANDERSON,

shown in Table II. The highest incidence was the 28% in

parous women which compared with 16.7% in nulliparous
women (p = 0.043). The 7.5% incidence in men was only
half of that of nulliparous women (p = 0.031).
The number of pregnancies in parous women is shown in
Figure 1, with the percentage incidence of degenerative
spondylolisthesis for each number (Fig. 2). This shows a
trend towards an increasing incidence with a greater number of pregnancies, but the difference did not reach statistical signicance (p = 0.08).

DISCUSSION
Our study can be criticised because the patients were
preselected by signicant low back symptoms which
required referral to a spine surgeon. Despite this we believe
that the groups probably represent the general population
fairly accurately. This is supported by our results for the
relative incidence in men and women and at different
lumbar levels; these are virtually identical to other pub-

R. D. FRASER

lished gures. The relatively large numbers which were

involved in the study may also help to offset any bias.
Our results indicate that the increased incidence of
degenerative spondylolisthesis in women with back pain
cannot be entirely attributed to pregnancy since nulliparous
women showed twice the incidence of that in men, but
there was a signicant increase in relation to parity. This
trend did not reach statistical signicance because of the
relatively low numbers of women with large families.
There are many physiological changes during pregnancy,
and relaxation of the pelvic and other joints is an essential
and normal feature (Abramsom, Roberts and Wilson 1934).
This change correlates with the levels of the hormone
relaxin (Zarrow, Holmstrom and Salhanick 1955). It has
been shown that parous women have signicantly greater
laxity than nulliparous women but after the rst pregnancy
laxity did not change with the number of pregnancies
(Calguneri, Bird and Wright 1982). The action of relaxin is
not fully understood, but it appears to increase the tissue
level of collagenase (Mazouijian and Bryant-Greenwood

Table II. The number and percentage incidence of degenerative spondylolisthesis in

nulliparous and parous women and in men related to the level affected

Level

Nulliparous

Parous

Number
(n = 96)

Number
(n = 853)

Per cent

Men
Per cent

Number
(n = 120)

Per cent

L5/S1

1.1

23

2.7

1.7

L4/L5

13

13.5

182

21.3

5.0

L3/L4

2.1

34

4.0

0.8

Total

16

16.7*

239

28.0*

7.5

* difference: p = 0.043
difference: p = 0.031

Fig. 1

Fig. 2

Number of pregnancies in 949 women with low back pain.

The incidence of degenerative spondylolisthesis related to the number of

pregnancies.
THE JOURNAL OF BONE AND JOINT SURGERY

THE INFLUENCE OF PREGNANCY ON THE DEVELOPMENT OF DEGENERATIVE SPONDYLOLISTHESIS

1990), and it has been shown that it increases the ability of

skin to expand as a result of a change in the collagen
structure (Kibblewhite, Larrabee and Sutton 1992).
There is some evidence that the generalised effect on
joint relaxation may have long-term effects, persisting for
years after delivery in some women (Saugstad 1991). Joint
laxity and instability are recognised as a feature of degenerative spondylolisthesis (Postacchini and Perugia 1991), and
it is possible that relaxin affects the collagen of the facet
joint capsules which limit rotation of the spinal motion
segment (Gunzburg et al 1992). Relaxin may also affect the
collagen of the annulus, again reducing the stability of the
motion segment. The greater joint laxity in women than in
men (Harris and Joseph 1949; Beighton, Solomon and
Soskolne 1973) may be a factor in the difference in the
incidence of degenerative spondylolisthesis between nulliparous women and men.
During pregnancy, the large exion moment on the lower
back is reported to be equivalent to the loads imposed on
the spine of a non-pregnant woman with her trunk exed

forwards by 22 (Ostgaard
et al 1993). This increase in
loading of the lumbar spine may inuence the development
of degenerative spondylolisthesis. Rosenberg (1975) has
shown that patients with an increased lordosis have a
higher incidence of degenerative spondylolisthesis. It is
often assumed that there is an increase in lumbar lordosis

during pregnancy, but this is a misconception. Ostgaard

et
al (1993) have shown that carrying a child is accommodated by extension of the hips and that the lumbar lordosis
does not change during pregnancy. These postural changes
are therefore unlikely to account for the increased incidence
of degenerative spondylolisthesis in multiparous women.
A third, and possibly the most important factor, is the
effect of pregnancy in reducing the tone of the abdominal
muscles (Omatsu 1957). We were unable to nd any reports
regarding the strength and tone of these muscles after
delivery, but the senior author (RDF) has noted during
anterior surgery on the lumbar spine that in multiparous
women rectus abdominis is often widely separated with
associated wasting of the abdominal musculature. Poor
muscular tone may be a contributing factor in joint hypermobility (Beimborn and Morrissey 1988). Weak muscles
may allow an increase in sheer forces on the L4/L5 joints,
and lead to the rotatory deformity seen in degenerative
spondylolisthesis. In support of this, it is interesting that
exion exercises to strengthen the abdominal muscles give
better results than extension exercises in the conservative
management of spondylolisthesis (Sinaki et al 1989).
Low back pain is common in pregnancy with a reported
prevalence of 81% (Kristiansson, Svardsudd and Schoultz
1996), but we have found no reports of specic conditions
of the spine which are inuenced by pregnancy. It has been
suggested that scoliosis may accelerate during pregnancy,
but this view is controversial. Berman, Cohen and
Schwentker (1982) reported that scoliotic curves deteriorated during pregnancy in three of the eight patients who
VOL. 78-B, NO. 6, NOVEMBER 1996

953

were observed. By contrast, Betz et al (1987) found no

evidence that pregnancy affected the progression of scoliosis in a larger study of 355 patients.
Isthmic spondylolysis with or without slip is not affected
by pregnancy (Saraste 1986), but this is not surprising
because of the distinct differences: it occurs most commonly at the L5/S1 level, is more frequent in men than in
women and develops in young patients (Roche and Rowe
1951).
The pathogenesis is also different; the cause appears to
be the repetitive exion-extension activity of athletes and
gymnasts (Letts et al 1986).
Conclusion. The incidence of degenerative spondylolisthesis in patients with low back pain is almost twice as high
in parous as in nulliparous women. The reasons are not
clear, but there is a need for further research on the changes
in the abdominal muscles and in the ligaments and joint
capsules of the spine after parturition. This may have
important implications for the development of effective
methods of prevention.
No benets in any form have been received or will be received from a
commercial party related directly or indirectly to the subject of this
article.

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