CLINICAL ARTICLE

J Neurosurg Spine 37:535–540, 2022

Utility of a fulcrum for positioning support during

flexion-extension radiographs for assessment of lumbar
instability in patients with degenerative lumbar
spondylolisthesis
*Fanguo Lin, MD,1 Zhiqiang Zhou, MD,1 Zhiwei Li, MD,2 Bingchen Shan, MD,1 Zhentao Zhou, PhD,1
Yongming Sun, PhD,1 and Xiaozhong Zhou, PhD1
1
Department of Orthopedics and 2Department of Radiology, The Second Affiliated Hospital of Soochow University, Suzhou, China

OBJECTIVE  The authors investigated a new standardized technique for evaluating lumbar stability in lumbar lateral
flexion-extension (LFE) radiographs. For patients with lumbar spondylolisthesis, a three-part fulcrum with a support plat-
form that included a semiarc leaning tool with armrests, a lifting platform for height adjustment, and a base for stability
were used. Standard functional radiographs were used for comparison to determine whether adequate flexion-extension
was acquired through use of the fulcrum method.
METHODS  A total of 67 consecutive patients diagnosed with L4–5 degenerative lumbar spondylolisthesis were enrolled
in the study. The authors analyzed LFE radiographs taken with the patient supported by a fulcrum (LFEF) and without a
fulcrum. Sagittal translation (ST), segmental angulation (SA), posterior opening (PO), change in lumbar lordosis (CLL),
and lumbar instability (LI) were measured for comparison using functional radiographs.
RESULTS  The average value of SA was 5.76° ± 3.72° in LFE and 9.96° ± 4.00° in LFEF radiographs, with a significant
difference between them (p < 0.05). ST and PO were also significantly greater in LFEF than in LFE. The detection rate of
instability was 10.4% in LFE and 31.3% in LFEF, and the difference was significant. The CLL was 27.31° ± 11.96° in LFE
and 37.07° ± 12.963.16° in LFEF, with a significant difference between these values (p < 0.05).
CONCLUSIONS  Compared with traditional LFE radiographs, the LFEF radiographs significantly improved the detection
rate of LI. In addition, this method may reduce patient discomfort during the process of obtaining radiographs.
https://thejns.org/doi/abs/10.3171/2022.3.SPINE22192
KEYWORDS  flexion-extension; radiographs; fulcrum; instability; degenerative lumbar spondylolisthesis

D
egenerative lumbar spondylolisthesis (DLS) is
a common condition of the lumbar spine.1,2 Sur-
gery should be considered in patients experiencing
from recalcitrant back pain or nerve irritation, as well as in
patients in whom conservative therapy has failed.3–5 While
planning the operation, neurosurgeons should determine
whether the patient’s condition is accompanied by lum-
bar instability (LI).6–9 At present, lateral flexion-extension
(LFE) standing radiographs are the most widely used tool
for evaluating lumbar stability.10 However, the quality of
these images is frequently decreased because patient co-
operation has a large effect on functional radiographic
imaging, and different degrees of patient pain tolerance
and cooperation may lead to variations in examination re-
sults.11–13
In recent years, both auxiliary examination methods
for LI and the accuracy of radiographic positioning have
developed rapidly, giving rise to technologies such as trac-
tion positioning during radiographic examination and su-
pine scanning using CT or MRI. However, these examina-
tion methods are expensive and may be cumbersome, and
hence they cannot be widely performed in the clinical set-
ting.13–16 In an effort to deal with this problem, we have de-
veloped a new standardized technique for evaluating lum-

ABBREVIATIONS  CLL = change in LL; DLS = degenerative lumbar spondylolisthesis; LFE = lateral flexion-extension; LFEF = LFE with fulcrum; LI = lumbar instability; LL
= lumbar lordosis; PO = posterior opening; SA = segmental angulation; ST = sagittal translation.
SUBMITTED  February 10, 2022.  ACCEPTED  March 21, 2022.
INCLUDE WHEN CITING  Published online May 6, 2022; DOI: 10.3171/2022.3.SPINE22192.
* Fanguo Lin, Zhiqiang Zhou, and Zhiwei Li contributed equally to this work and share first authorship.

©AANS 2022, except where prohibited by US copyright law J Neurosurg Spine  Volume 37 • October 2022 535

Brought to you by AOSpine | Unauthenticated | Downloaded 06/23/23 10:58 AM UTC

Lin et al.

FIG. 1. A and B: The fulcrum consists of three parts. The top is the support platform, including the semiarc leaning tool with
armrests on both sides. The patient can hold the armrest with both hands to maintain body balance. The middle part is a lifting
platform that can be adjusted according to the height of the patient. The bottom layer is a four-corner base that provides the stabil-
ity of the fulcrum. C and D: During the flexion radiographs, the patient stood upright facing the fulcrum from a close distance. The
patient held the armrest on both sides of the fulcrum and bent forward to the maximum extent. At this time, the stress flexion ra-
diographs were taken. E and F: Then the patient turned their body and held the armrests on the two sides of the fulcrum with both
hands to maintain body balance with the body tilted back as much as they could. At this time, the stress extension radiographs
were taken. Figure is available in color online only.

bar stability, performing LFE radiographs with a fulcrum
for patient support during positioning. In this study, we
evaluated whether the use of this technique can improve
the detection rate of LI in patients with DLS.
Methods
Design and Manufacture of the Fulcrum
The fulcrum includes three parts (Fig. 1A and B). The
upper part is the support platform (height 30 cm), which
includes the semiarc leaning bench with an armrest on
both sides. The semiarc leaning bench is made of polyeth-
ylene, which allows the penetration of rays to ensure that
the film is clear and measurable. The armrest can be ad-
justed according to the degree of patient bending required
and may help the patient stand steadily during the exami-
nation process. This support system may also reduce pa-
tient anxiety. The middle of the fulcrum has an adjustable
lifting platform with a wheel on the side that allows height
adjustment (height range 9–35 cm). The operation is sim-
ple and convenient. At the bottom of the leaning bench
there is a four-corner bracket that stabilizes the whole ap-
paratus (height 30 cm).
Study Patients
A total of 67 patients with L4–5 DLS underwent sur-
gery in our hospital from January 2021 to December 2021
(40 men and 27 women; mean age 58.49 ± 15.10 years).
The inclusion criteria were as follows: 1) single-level
grade 1 lumbar spondylolisthesis (L4–5) demonstrated by
standard lumbar radiographs, including anteroposterior
and lateral radiographs; 2) presentation with persistent
mechanical low-back and radicular leg pain after more
than 6 months of conservative treatment; and 3) CT im-
aging taken after admission. Exclusion criteria included
positive history of any of the following: previous thoraco-
lumbar surgery, acute spinal trauma, tumor, spondylolysis,
ankylosing spondylitis, multilevel lumbar spondylolisthe-
sis, and severe scoliosis. This study was reviewed and ap-
proved by the ethics committee of the hospital, and writ-
ten informed consent was obtained from all participants in
this study. After admission, all patients underwent lumbar
spine radiography that included traditional (LFE) radio-
graphs and LFE with fulcrum (LFEF) radiographs.
Inspection Method
The fulcrum was 1 m away from and perpendicular
to the radioactive source. During the flexion radiographs
(Fig. 1C and D), the patient stood upright facing the ful-
crum from a close distance, and the height of the fulcrum
was adjusted to the level of the bilateral iliac crest. The
patient held the armrest on both sides of the fulcrum with
both hands to maintain body balance, and then bent for-
ward to the maximum extent. At this time, the stress flex-
ion radiographs were taken. The patient then turned their
body and stayed close to the fulcrum, holding the armrests
on the two sides of the fulcrum with both hands to main-
tain body balance with the body tilted back as much as
possible without discomfort. At this time, the stress exten-
sion radiographs (Fig. 1E and F) were taken.
Data Measurement
All radiographs were taken by two radiologists with 5
years of experience in musculoskeletal system imaging.
Three spine surgeons with more than 10 years of experi-
ence completed the measurements independently. All the
spine surgeons were blinded to the patients and the de-
vice. The average values of the measured data were the

536 J Neurosurg Spine  Volume 37 • October 2022

Brought to you by AOSpine | Unauthenticated | Downloaded 06/23/23 10:58 AM UTC

 Lin et al.

FIG. 2. A and B: Measurement used in the study. For ST, the anterior translation of L4 was recorded with positive numbers, and
the posterior translation was recorded with negative numbers. The difference between the two distances was defined as the
amount of ST (a − a1). For SA, the difference of intervertebral angles between flexion and extension radiographs was calculated (β1
− β). For PO, the intervertebral angle on the flexion radiograph was measured (−β). Next, to determine the CLL, LL was measured
as the angle between the cranial L1 and cranial S1 vertebral endplates (α, α1). After that, the difference of LL angles between
flexion and extension radiographs was calculated (α1 − α). C–F: The flexion and extension images of a patient aged 40–49 years
showed higher segmental translation when obtained with the fulcrum (E and F) than without the fulcrum (C and D) (3.74 vs 0.95
mm, respectively). Furthermore, SA and CLL measured with patients supported by the fulcrum were larger than those measured
without the fulcrum (16° vs 2°, and 53° vs 22°, respectively). A PO of 7° was noted in the flexion image with the fulcrum. Figure is
available in color online only.

final data. All data were measured using radiology soft- 2.64 ± 1.45 mm in LFEF radiographs, with a significant
ware (Neusoft PACS/RIS) to reduce variability. Measure- difference between them (p < 0.05; Table 1). There were
ments were taken with the patient in the neutral position, 6 patients (8.96%) with an ST ≥ 3 mm in LFE and 20 pa-
extension position, flexion position, stress extension po- tients (29.85%) with an ST ≥ 3 mm in LFEF radiographs.
sition, and stress flexion position (Fig. 2A and B). Sagit- The value of SA in LFE was 5.76° ± 3.72°, and the value of
tal translation (ST), segmental angulation (SA), posterior SA in LFEF radiographs was 9.96° ± 4.00°, with the dif-
opening (PO), and change in lumbar lordosis (CLL) were ference being significant (p < 0.05; Table 1). One of 67 pa-
also measured. LI was defined as ST ≥ 3 mm or SA ≥ 20° tients (1.49%) showed an SA ≥ 20° in LFEF radiographs,
on flexion-extension radiographs, or PO ≥ 5° on flexion and this patient was also one of the patients who showed
radiographs.17,18 The whole and relative data of ST, SA, an ST ≥ 3 mm in LFEF radiographs. No patients showed
and PO and the detection rates on LFEF radiographs were an SA ≥ 20° in LFE radiographs.
compared with those of LFE. In addition, the amount of The results of PO measurement were −2.07° ± 3.45°
flexion-extension was assessed through the CLL on flex- in LFE and −0.55° ± 3.83° in LFEF radiographs, with
ion-extension radiographs and compared between LFE a significant difference between these values (p < 0.05;
and LFEF radiographs. Table 1). Four of 67 patients (6.0%) showed a PO ≥ 5° in
LFEF, and none showed a PO ≥ 5° in LFE radiographs.
Data Analysis
All statistical tests were conducted using IBM SPSS
version 20.0 (IBM Corp.). Continuous variables are pre-
sented as mean ± standard deviation. A paired t-test was TABLE 1. ST, SA, PO, and CLL measured in flexion-extension
used to assess the SA, CLL, ST, and PO differences be- radiographs taken with or without a fulcrum for patient support
tween LFEF and LFE. A chi-square test or Fisher exact Fulcrum
test was used to compare the ratios of the PO ≥ 5° and LI Variable w/ w/o t p Value
between LFEF and LFE; p < 0.05 was considered signifi-
cant. ST, mm 2.64 ± 1.45 1.32 ± 1.05 −9.329 <0.001
SA, ° 9.96 ± 4.00 5.76 ± 3.72 −8.097 <0.001
Results CLL, ° 37.07 ± 13.16 27.31 ± 11.96 −7.075 <0.001
A total of 67 patients with L4–5 grade 1 DLS were PO, ° −0.55 ± 3.83 −2.07 ± 3.45 −5.360 <0.001
enrolled in this study (40 men and 27 women with an av- Values are presented as mean ± SD unless otherwise indicated. For all vari-
erage age of 58.49 ± 15.10 years). The measurement of ST ables, values measured with the fulcrum were significantly higher than those
revealed an absolute value of 1.32 ± 1.05 mm in LFE and measured without the fulcrum.

J Neurosurg Spine  Volume 37 • October 2022 537

Brought to you by AOSpine | Unauthenticated | Downloaded 06/23/23 10:58 AM UTC

Lin et al.
TABLE 2. Comparison of PO and LI in flexion-extension
radiographs taken with or without a fulcrum for patient support
Radiography Results (n = 67)
Yes No
LI
  w/ fulcrum 21 (31.3) 46 (687)
  w/o fulcrum 7 (10.4) 60 (89.6)
PO, ≥5°
  w/ fulcrum 4 (6.0) 63 (94.0)
  w/o fulcrum 0 67 (100)
Values are presented as number (%) of patients unless otherwise indicated.
* Chi-square test; chi-square value = 17.122.
† Fisher exact test.
The number of patients with LI was 7 (10.4%) in LFE and
21 (31.3%) in LFEF. Four of 67 patients (5.97%) showed
a PO ≥ 5° in LFEF, and none met this threshold in LFE
radiographs (Table 2). Of the 4 patients with a PO ≥ 5° in
LFEF, 3 patients showed an ST ≥ 3 mm in LFEF, and 1 pa-
tient did not meet the conditions of ST and SA LI in LFEF
radiographs, indicating that the PO should be a separate
factor in the process of LI detection.
The mean CLL measurements were 27.31° ± 11.96° in
LFE and 37.07° ± 13.16° in LFEF, with a significant differ-
ence between these values (p < 0.05; Table 1). This result
indicated that the range of motion changes measured for
lumbar lordosis (LL) were significantly increased in LFEF
compared with LFE radiographs. There were 7 patients
(10.4%) with LI in LFE and 21 (31.3%) with LI in LFEF,
and this difference was also significant (p < 0.05; Table
2). LFEF radiographs can decrease the false-negative
rate compared with that for imaging without the fulcrum.
There were 14 patients with LI detected in LFEF radio-
graphs who had false-negative results in LFE radiographs
taken without the fulcrum. When asked about discomfort
during the radiographic examinations, 64 patients felt
more comfortable with the fulcrum. Three patients with
severe back pain who reported unbearable pain when they
extended and flexed their waist slightly reported feeling
little difference between the two methods.
The flexion and extension images of these patients,
aged 40–49 years, showed higher segmental translation in
LFEF radiographs than in LFE radiographs taken without
the fulcrum (3.74 vs 0.95 mm). Furthermore, SA and CLL
measurements were larger when taken while patients were
supported with the fulcrum than without fulcrum support
(16° vs 2° and 53° vs 22°, respectively). A PO of 7° was
noted in the flexion image taken with fulcrum support
(Fig. 2C–F).
Discussion
In our study, we tested a new method of obtaining lum-
bar LFE radiographs with the patient support provided by
a fulcrum, which may be useful as a standardized tech-
nique for evaluating abnormal lumbar activity and lumbar
stability. The fulcrum includes three parts to provide sup-
port to the patient for leaning forward and backward and
538 J Neurosurg Spine  Volume 37 • October 2022
Brought to you by AOSpine | Unauthenticated | Downloaded 06/23/23 10:58 AM UTC
can be disassembled to facilitate handling. When lumbar
LFEF radiographs are being taken, patients can hold the
armrest in the support platform, which can reduce the fear
p Value
of falling and allow patients to better complete the process
of obtaining the radiographs. In this study, we have for-
mulated the specifications and processes for taking lum-
<0.001* bar LFEF radiographs and demonstrated that this method
can reduce interference of human factors in the process
of obtaining accurate radiographic data with good repeat-
ability.
0.119† To the best of our knowledge, LI does not have spe-
cific symptoms or signs, and there are as of yet no unified
diagnostic criteria to detect this condition.19–22 Flexion-
extension lateral radiographs taken with the patient in the
standing position are the most widely used tools to evalu-
ate radiological lumbar stability. However, the details of
performing this imaging method may vary across institu-
tions. In addition, spinal surgeons have various viewpoints
regarding the definition of abnormal mobility in LI.8,9,23,24
In the past few years, great progress has been made in
the radiological examination and evaluation of lumbar
stability. Landi et al. studied the use of dynamic projec-
tions in standing and recumbent positions in 200 patients
with LI.25 The detection rates of instability in L4–5 radio-
graphs were 14.3% with the patient in a standing position
and 11.6% with the patient in a recumbent position. In our
study, there were 21 patients (31.3%) with abnormal insta-
bility detected in LFEF radiographs. This detection rate
was higher than that reported by Landi et al. Tarpada et al.
demonstrated that the addition of a supine radiograph to
the standard spondylolisthesis evaluation shows more re-
duction in anterolisthesis than an extension radiograph.26
Flexion-supine radiographs show more vertebral mobility
and reduction and thus may be more appropriate for the
initial evaluation of lumbar spondylolisthesis than flexion-
extension radiographs. The mean mobility with flexion-
supine radiographs reported by Tarpada et al. was 7.83%
± 4.67%. Morita et al. analyzed flexion-extension radio-
graphs in patients led by hand to provide assistance with
positioning and those not led by hand.18 The measurement
of ST indicated an absolute value of 3.8 ± 1.7 mm in pa-
tients with this positioning assistance and 2.2 ± 1.3 mm in
patients without it.
Study findings determined with LFE radiographs are
frequently questioned because patient cooperation has an
important effect on functional radiographic imaging, and
different degrees of pain tolerance and cooperation in the
patient may cause different examination results. There-
fore, a rapid, convenient, and less cumbersome detection
tool is urgently needed. In an effort to resolve this issue,
we designed a fulcrum for patient positioning during radi-
ography as a tool for enhancing detection of LI and tested
its use in this study. The height of the positioning fulcrum
can be adjusted to the height of the patient, so that the
highest point of the auxiliary detection platform is parallel
to the level of the bilateral iliac crests. The standardized
application of this process can reduce measurement devia-
tions on radiographs to the greatest extent. In this study,
we found that low-back pain or poor posture may lead to
underestimation of LI in patients who undergo LFE radi-
ography without support. When LFEF radiographs were

taken of the same patients while supported with the ful-
crum, the burden on muscles and ligaments used by the
patient to maintain the position of extension or flexion in
the waist and back was reduced. Thus, the symptoms of
lumbar pain were greatly relieved. This improvement in
the comfort of patients during radiography led to more
successful results.
Our study included 67 patients with L4–5 DLS. The
measurement of ST revealed an absolute value of 2.64 ±
1.45 mm in LFEF radiographs, which was significantly
higher than that in LFE radiographs. There were 6 pa-
tients (8.96%) with an ST ≥ 3 mm in LFE and 20 patients
(29.85%) with an ST ≥ 3 mm in LFEF. This difference
indicated that flexion-extension radiographs obtained with
fulcrum support of the patient can display ST instability
more clearly. Meanwhile, we also obtained results show-
ing that compared with LFE, LFEF can significantly im-
prove the measurement of SA and PO. Four of 67 patients
(5.97%) showed a PO ≥ 5° in LFEF, and 1 patient did not
meet the conditions of ST and SA LI in LFEF radiographs.
These findings indicate that the PO should be treated as a
separate factor in the process of LI detection. The chang-
es of LL were significantly greater in LFEF than in LFE
without fulcrum radiographs, which indicates that patients
can complete the lumbar activities needed to obtain accu-
rate radiographs more safely and comfortably with assis-
tance of this auxiliary tool. LI was detected in 7 patients
(10.4%) with LFE radiographs obtained without the ful-
crum and 21 patients (31.3%) with LFEF radiographs, and
this difference was also significant. In the present study,
the detection rate of LI was improved by use of a fulcrum
for patient support (31.3% vs 10.4%), and missed diagnosis
of LI caused by low-back pain and the inability of the pa-
tient to cooperate with the examination without auxiliary
support was avoided.
There are also some limitations to this study. First, our
sample of 67 patients was small. Furthermore, the defini-
tion of instability (ST ≥ 3 mm or SA ≥ 20° on flexion-ex-
tension radiographs, or PO ≥ 5° in this study) was calculat-
ed with the data of standard flexion-extension radiography
without the use of a fulcrum. Our next step is to measure
the lumbar spine values of healthy individuals without
spinal pain or instability using standard flexion-extension
radiography with a fulcrum with the goal of formulating
the reference values for LI measured with fulcrum support
of the study participants.
Conclusions
This study shows that compared with traditional LFE
radiographs obtained without support provided for patient
positioning, LFEF radiographs with integrated patient
positioning support can make the process safer and more
comfortable by reducing the patient’s fear and back pain,
which leads to improved positioning and more accurate
results. The findings show that the ST, SA, and PO mea-
surements on LFEF radiographs were significantly greater
than those on LFE radiographs obtained without fulcrum
support. The LFEF method enables the acquisition of ac-
curate hyperextension and flexion images and is thus wor-
thy of further clinical application and promotion.
Brought to you by AOSpine | Unauthenticated | Downloaded 06/23/23 10:58 AM UTC
Lin et al.
References
  1. Allegri M, Montella S, Salici F, et al. Mechanisms of low
back pain:​a guide for diagnosis and therapy. F1000Res.
2016;​5:​F1000 Faculty Rev-1530.
  2. Huang M, Buchholz A, Goyal A, et al. Impact of surgeon
and hospital factors on surgical decision-making for grade 1
degenerative lumbar spondylolisthesis:​a Quality Outcomes
Database analysis. J Neurosurg Spine. 2021;​34(5):​768-778.
  3. Bisson EF, Guan J, Bydon M, et al. Patient-reported outcome
improvements at 24-month follow-up after fusion added to
decompression for grade I degenerative lumbar spondylo-
listhesis:​a multicenter study using the Quality Outcomes
Database. J Neurosurg Spine. 2021;​35(1):​42-51.
  4. Chan AK, Bisson EF, Bydon M, et al. A comparison of mini-
mally invasive and open transforaminal  lumbar  interbody
fusion for grade 1 degenerative  lumbar  spondylolisthesis:​
an analysis of the prospective Quality Outcomes Database.
Neurosurgery. 2020;​87(3):​555-562.
  5. Haddas R, Sandu CD, Mar D, Block A, Lieberman I. Lumbar
decompression and interbody fusion improves gait per-
formance, pain, and psychosocial factors of patients with
degenerative lumbar spondylolisthesis. Global Spine J. 2021;​
11(4):​472-479.
  6. Ghogawala Z, Dziura J, Butler WE, et al. Laminectomy plus
fusion versus laminectomy alone for lumbar spondylolisthe-
sis. N Engl J Med. 2016;​374(15):​1424-1434.
  7. Austevoll IM, Gjestad R, Brox JI, et al. The effectiveness of
decompression alone compared with additional fusion for
lumbar spinal stenosis with degenerative spondylolisthesis:​
a pragmatic comparative non-inferiority observational study
from the Norwegian Registry for Spine Surgery. Eur Spine J.
2017;​26(2):​404-413.
  8. Försth P, Ólafsson G, Carlsson T, et al. A randomized, con-
trolled trial of fusion surgery for lumbar spinal stenosis. N
Engl J Med. 2016;​374(15):​1413-1423.
  9. Sigmundsson FG, Jönsson B, Strömqvist B. Outcome of de-
compression with and without fusion in spinal stenosis with
degenerative spondylolisthesis in relation to preoperative
pain pattern:​a register study of 1,624 patients. Spine J. 2015;​
15(4):​638-646.
10. Wood KB, Popp CA, Transfeldt EE, Geissele AE. Radio-
graphic evaluation of instability in spondylolisthesis. Spine
(Phila Pa 1976). 1994;​19(15):​1697-1703.
11. Zhou QS, Sun X, Chen X, et al. Utility of natural sitting
lateral radiograph in the diagnosis of segmental instability
for patients with degenerative lumbar spondylolisthesis. Clin
Orthop Relat Res. 2021;​479(4):​817-825.
12. Temes B, Karas S, Manwill J. Assessment of lumbar spine
instability using C-arm fluoroscopy. J Orthop Sports Phys
Ther. 2016;​46(9):​810.
13. Hey HW, Lau ET, Lim JL, et al. Slump sitting X-ray of the
lumbar spine is superior to the conventional flexion view in
assessing lumbar spine instability. Spine J. 2017;​17(3):​360-
368.
14. Cho IY, Park SY, Park JH, Suh SW, Lee SH. MRI findings of
lumbar spine instability in degenerative spondylolisthesis. J
Orthop Surg (Hong Kong). 2017;​25(2):​2309499017718907.
15. Kao Y, Liu Z, Leng J, et al. A preoperative predictive model
of lower lumbar spine instability based on three-dimensional
computed tomography:​a retrospective case-control pilot
study. Orthop Surg. 2021;​13(2):​484-492.
16. Charest-Morin R, Zhang H, Shewchuk JR, et al. Dynamic
morphometric changes in degenerative lumbar spondylolis-
thesis:​a pilot study of upright magnetic resonance imaging. J
Clin Neurosci. 2021;​91:​152-158.
17. Yoshimoto M, Miyakawa T, Takebayashi T, et al. Microen-
doscopy-assisted muscle-preserving interlaminar decompres-
sion for lumbar spinal stenosis:​clinical results of consecutive
J Neurosurg Spine  Volume 37 • October 2022 539
Lin et al.
105 cases with more than 3-year follow-up. Spine (Phila Pa
1976). 2014;​39(5):​E318-E325.
18. Morita T, Yoshimoto M, Terashima Y, et al. Do we have ad-
equate flexion-extension radiographs for evaluating instabil-
ity in patients with lumbar spondylolisthesis? Spine (Phila Pa
1976). 2020;​45(1):​48-54.
19. Alyazedi FM, Lohman EB, Wesley Swen R, Bahjri K. The
inter-rater reliability of clinical tests that best predict the
subclassification of lumbar segmental instability:​structural,
functional and combined instability. J Manual Manip Ther.
2015;​23(4):​197-204.
20. Areeudomwong P, Jirarattanaphochai K, Ruanjai T, Buttagat
V. Clinical utility of a cluster of tests as a diagnostic support
tool for clinical lumbar instability. Musculoskelet Sci Pract.
2020;​50:​102224.
21. Sriphirom P, Siramanakul C, Chaipanha P, Saepoo C. Clin-
ical outcomes of interlaminar percutaneous endoscopic
decompression for degenerative lumbar spondylolisthesis
with spinal stenosis. Brain Sci. 2021;​11(1):​E83.
22. Dombrowski ME, Rynearson B, LeVasseur C, et al. ISSLS
Prize in Bioengineering Science 2018:​dynamic imaging of
degenerative spondylolisthesis reveals mid-range dynamic
lumbar instability not evident on static clinical radiographs.
Eur Spine J. 2018;​27(4):​752-762.
23. Iyer S, Lenke LG, Nemani VM, et al. Variations in sagittal
alignment parameters based on age:​a prospective study of
asymptomatic volunteers using full-body radiographs. Spine
(Phila Pa 1976). 2016;​41(23):​1826-1836.
24. Viswanathan VK, Hatef J, Aghili-Mehrizi S, Minnema AJ,
Farhadi HF. Comparative utility of dynamic and static im-
aging in the management of lumbar spondylolisthesis. World
Neurosurg. 2018;​117:​e507-e513.
25. Landi A, Gregori F, Marotta N, Donnarumma P, Delfini R.
Hidden spondylolisthesis:​unrecognized cause of low back
540 J Neurosurg Spine  Volume 37 • October 2022
Brought to you by AOSpine | Unauthenticated | Downloaded 06/23/23 10:58 AM UTC
pain? Prospective study about the use of dynamic projections
in standing and recumbent position for the individuation of
lumbar instability. Neuroradiology. 2015;​57(6):​583-588.
26. Tarpada SP, Cho W, Chen F, Amorosa LF. Utility of supine
lateral radiographs for assessment of lumbar segmental insta-
bility in degenerative lumbar spondylolisthesis. Spine (Phila
Pa 1976). 2018;​43(18):​1275-1280.
Disclosures
The authors report no conflict of interest concerning the materi-
als or methods used in this study or the findings specified in this
paper.
Author Contributions
Conception and design: all authors. Acquisition of data: Lin,
Zhiqiang Zhou, Li, Shan, Zhentao Zhou, Sun. Analysis and inter-
pretation of data: X Zhou, Lin, Zhiqiang Zhou, Li. Drafting the
article: X Zhou, Lin, Zhiqiang Zhou, Li. Critically revising the
article: all authors. Reviewed submitted version of manuscript: all
authors. Approved the final version of the manuscript on behalf of
all authors: X Zhou. Statistical analysis: Lin, Zhiqiang Zhou, Li.
Administrative/technical/material support: Lin, Zhiqiang Zhou,
Li, Shan, Zhentao Zhou, Sun. Study supervision: Lin, Zhiqiang
Zhou, Li.
Correspondence
Xiaozhong Zhou: The Second Affiliated Hospital of Soochow
University, Suzhou, China. xiaozhongzhou01@163.com.