Imaging-Based Evaluation of Predictive Factors in Single- and Double-Level Isthmic Spondylolisthesis: A Comparative and Correlational Study

Imaging-Based Evaluation of Predictive Factors in Single- and Double-Level Isthmic Spondylolisthesis: A Comparative and Correlational Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Imaging-Based Evaluation of Predictive Factors in Single- and Double-Level Isthmic Spondylolisthesis: A Comparative and Correlational Study YuanXuan Li, Yao Chen, XinWei Fu, ChaoHua Yang, Qing Wang, Jin Yang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8025252/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Objectives To compare sagittal alignment, disc degeneration, and paraspinal muscle status between patients with single-level L5 isthmic spondylolisthesis (L5-IS) and double-level isthmic spondylolisthesis (DLIS), and to evaluate predictive factors for DLIS. Methods Sagittal parameters including pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), and lumbar lordosis (LL), as well as the cross-sectional areas of multifidus (MF CSA) and erector spinae (ES CSA), were measured. Comparative analysis, correlation analysis, and multivariate logistic regression were conducted. Results A total of 64 patients were included: 32 with DLIS and 32 with L5-IS. The DLIS group showed higher PI (60.56 ± 9.50 vs. 51.89 ± 9.70, P < 0.001) and PT (28.33 ± 9.31 vs. 20.91 ± 9.70, P = 0.03), but smaller MF-CSA (0.39 ± 0.12 vs. 0.49 ± 0.13, P = 0.002) and ES-CSA (0.82 ± 0.31 vs. 1.17 ± 0.38, P < 0.001). PI and PT were strongly correlated in both groups. Logistic regression identified increased PI (OR = 1.098), PT (OR = 2.090), and SS (OR = 2.014) as potential predictive factors. Receiver Operating Characteristic (ROC) curve analysis showed acceptable predictive performance for PI (AUC = 0.751) and PT (AUC = 0.711), while SS had limited value (AUC = 0.612). Conclusion DLIS patients exhibit greater pelvic parameters and paraspinal muscle atrophy. PI and PT may have predictive value for DLIS. Double-level isthmic spondylolisthesis L5 isthmic spondylolisthesis sagittal alignment parameters disc degeneration paraspinal muscles predictive factors propensity score matching Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Isthmic spondylolisthesis (IS) is a common form of lumbar spondylolisthesis, most often occurring at the L5 vertebra as single-level isthmic spondylolisthesis (L5-IS) [ 1 ].Multi-level isthmic spondylolisthesis (MLIS) has a relatively low incidence and is often overlooked in clinical practice. It typically occurs at the L4 and L5 levels, though it may also affect the L3-L5 or L2-L5 segments [ 2 , 3 ].Although extensive research has been conducted on the etiology, pathophysiology, progression, diagnosis, and treatment of L5-IS[ 4 – 6 ],studies on MLIS are scarce, and the differences between the two remain unclear. These differences could significantly affect the understanding, evaluation, treatment planning, prognosis, and quality of life for MLIS patients. Spinal-pelvic balance and sagittal plane parameters are key factors in studying lumbar spondylolisthesis. Intervertebral disc degeneration and paraspinal muscle function also play critical roles in the development and progression of lumbar spondylolisthesis [ 7 ].The association of these factors with MLIS and their differences from L5-IS remain pressing clinical questions. Therefore, investigating the role of these factors in MLIS is crucial for enhancing its diagnosis and treatment. This study focuses on patients with Double-level isthmic spondylolisthesis (DLIS) as part of MLIS, comparing them with the L5-IS group. A retrospective analysis will compare sagittal parameters, intervertebral disc degeneration, and paraspinal muscle function between the two groups, using correlation analysis to identify predictive factors for DLIS occurrence. Materials and Methods Study Design A retrospective analysis of clinical and imaging data from patients diagnosed with IS between January 2018 and April 2025 in our department. The inclusion criteria were: (1)Age > 18 years at admission; ༈2༉ Imaging meets diagnostic criteria for DLIS with a slip degree < 50%; ༈3༉ No other spinal or orthopedic conditions affecting the results. The exclusion criteria were: ༈1༉ History of spinal surgery, trauma, or infection; ༈2༉Presence of spinal tumors, fractures, scoliosis, or lumbosacral transitional vertebrae; ༈3༉ Slip degree > 50%; ༈4༉Simple isthmic defect; ༈5༉ IS involving > two segments. Based on these criteria, 32 cases of DLIS and 100 cases of L5-IS were included. After Propensity Score Matching (PSM)[ 8 , 9 ], 32 patients from each group were included for analysis. The study was approved by the local ethics committee – due to its retrospective nature, informed consent was not deemed necessary (No: KY2025486).༈Fig. 1 ༉ Study Data Baseline data included gender, age, body mass index (BMI), disease duration, diabetes, smoking history, Oswestry Disability Index (ODI) score, Low Back Pain Visual Analogue Scale (LBP-VAS), and Leg Pain Visual Analogue Scale (LP-VAS). Imaging data included preoperative X-rays of the entire spine or lumbar spine (including both hips) in the standing lateral position, as well as Whole Spine Magnetic Resonance Imaging (WS-MRI), measuring the following sagittal parameters: Pelvic Incidence (PI), Pelvic Tilt (PT), Lumbar Lordosis (LL), Thoracic Kyphosis (TK), Sacral Slope (SS), Sagittal Vertical Axis (SVA), Area of Multifidi (A-MF), and Multifidus Cross-Sectional Area (MF-CSA), Erector Spinae Cross-Sectional Area (ES-CSA), and Vertebral Body Cross-Sectional Area (VB-CSA). Relative cross-sectional area (rCSA) was defined as the ratio of muscle CSA to the corresponding vertebral body CSA, reducing the influence of individual body size, weight, and height[ 8 ]. And degree of disc degeneration in the affected segments (Pfirrmann grading) were also assessed. In this study, the angle between the upper and lower endplates of adjacent vertebrae was defined as a study unit, with its Partial Lumbar Lordosis angle (partial Lumbar Lordosis, pLnL) measured (where 'n' represents a specific segment, e.g. pL4L for L4). The segment with the most severe disc degeneration in the DLIS group was used to assess intervertebral disc degeneration. (Fig. 2 )༈Fig. 3 ༉ Statistical Analysis Propensity score matching (PSM) was used to minimize selection bias between the groups. A caliper width of 0.2 was applied, and one-to-one nearest neighbor matching (greedy algorithm, without replacement) was performed using the “MatchIt” package in R (version 4.0.4, R Project for Statistical Computing, Vienna, Austria), as described by Austin[ 9 ]. Continuous variables were tested for normality. Normally distributed data were expressed as mean ± standard deviation, while categorical and ordinal data were expressed as frequencies or percentages. Student’s t-test were used for normally distributed continuous variables, and nonparametric tests were applied for non-normally distributed variables. The chi-square test was used for categorical variables, and the rank-sum test was applied for ordinal variables. Pearson correlation analysis was performed for normally distributed variables, whereas Spearman correlation was used for non-normally distributed or ordinal variables. Multivariate logistic regression analysis was conducted with PI, PT, LL, SS, TK, SVA, MF rCSA, and ES rCSA as covariates to evaluate predictive factors for DLIS. All statistical analyses were performed using SPSS version 24.0 (IBM, Chicago, IL, USA). A P-value < 0.05 was considered statistically significant. Results A total of 64 subjects participated in the study, with 32 in the DLIS group and 32 in the L5-IS group. No statistically significant differences were found between the two groups in gender distribution, BMI, ODI, disease duration, and LBP-VAS and LP-VAS (Table 1 ). No significant differences were observed in pLnL between the two groups (Table 2 ). Table 1 Comparison of data between the two groups DLIS Group(n = 32) L5-IS Group(n = 32) T/χ2 value P value Age(years) 61.97 ± 9.80 57.63 ± 10.52 2.495 0.115 Gender(M/%) 15(46.8) 13(40.6) 0.675 0.071 BMI(kg/m 2 ) 23.86 ± 4.03 24.81 ± 3.61 -1.683 0.947 Duration of the disease 12.10 ± 0.77 11.96 ± 0.84 0.654 0.513 Smoking(Y/%) 7(21.9) 5(15.6) 0.245 0.723 Diabetes(Y/%) 4(12.5) 5(15.6) 1.438 0.612 ODI 64.28 ± 4.56 65.68 ± 3.64 -1.241 0.225 LBP-VAS 4.48 ± 0.74 4.84 ± 0.85 -1.652 0.105 LP-VAS 5.48 ± 0.74 5.84 ± 0.85 -1.652 0.102 Pfirrmann classification III IV V 1 10 21 6 9 17 -2.531 -3.257 -1.576 0.162 0.731 0.132 Note Data are presented as number of patients or mean ± SD; DLIS: Double-level Isthmic Spondylolisthesis; L5-IS: L5 Isthmic Spondylolisthesis; M: Male; BMI: Body Mass Index; Y: Yes; ODI: Oswestry Disability Index; LBP-VAS: Low Back Pain on Visual Analogue Scale; LP-VAS: Leg Pain on Visual Analogue Scale; Pfirrmann classification[ 11 ] Table 2 Comparison of partial lumbar lordosis between the two groups DLIS Group(n = 32) L5-IS Group(n = 32) T value P value pL 1 L 5.25 ± 0.50 4.54 ± 0.45 1.046 0.300 pL 2 L 6.30 ± 0.63 7.35 ± 1.26 -0.742 0.462 pL 3 L 11.29 ± 0.61 9.57 ± 0.66 1.904 0.062 pL 4 L 15.09 ± 3.19 14.07 ± 0.70 0.314 0.756 pL 5 L 15.01 ± 0.94 17.77 ± 1.03 -1.970 0.053 Note pL n L partial Lumbar Lordosis( n represents a specific segment); DLIS Double-level Isthmic Spondylolisthesis; L5-IS L5 Isthmic Spondylolisthesis The DLIS group exhibited significantly larger PI (60.56 ± 9.50 vs. 51.89 ± 9.70, P < 0.001) and PT (28.33 ± 9.31 vs. 20.91 ± 9.70, P = 0.03), but significantly smaller MF rCSA (0.39 ± 0.12 vs. 0.49 ± 0.13, P = 0.002) and ES rCSA (0.82 ± 0.31 vs. 1.17 ± 0.38, P < 0.001), indicating more severe paraspinal muscle degeneration in the DLIS group. No significant differences were found in other parameters (Table 3 ). Table 3 Comparison of imaging parameters between the two groups DLIS Group(n = 32) L5-IS Group(n = 32) T value P value PI(°) 60.56 ± 9.50 51.89 ± 9.70 3.619 < 0.001 PT(°) 28.33 ± 9.31 20.91 ± 9.70 3.120 0.030 LL(°) 43.00 ± 9.00 39.58 ± 12.83 1.239 0.221 SS(°) 34.63 ± 6.78 31.33 ± 7.94 1.765 0.083 TK(°) 27.63 ± 6.13 31.08 ± 9.61 -1.714 0.091 SVA(cm) 3.17 ± 1.31 3.62 ± 1.20 -1.435 0.156 MF CSA(mm 2 ) 694.38 ± 160.49 701.71 ± 175.79 -0.174 0.862 ES CSA(mm 2 ) 1420.76 ± 309.43 1650.32 ± 452.74 -2.368 0.021 MF rCSA 0.39 ± 0.12 0.49 ± 0.13 -3.237 0.002 ES rCSA 0.82 ± 0.31 1.17 ± 0.38 -4.057 < 0.001 Note DLIS Double-level Isthmic Spondylolisthesis; L5-IS L5 Isthmic Spondylolisthesis; PI: Pelvic Incidence; PT: Pelvic Tilt; LL: Lumbar Lordosis; TK: Thoracic Kyphosis; SS: Sacral Slope; SVA: Sagittal Vertical Axis; MF CSA: Multifidi Cross-Sectional Area; ES CSA: Erector Spinae Muscle Cross-Sectional Area; MF: Multifidi; ES: Erector Spinae muscle; rCSA: relatively Cross-Sectional Area; mm: millimeter; Correlation analysis revealed that in the DLIS group, PI was strongly positively correlated with PT (r = 0.792, P < 0.001). MF rCSA was positively correlated with ES rCSA (r = 0.62, P < 0.05), and LL showed a weak correlation with TK (r = 0.43, P < 0.05) (Table 4 ). In the L5-IS group, PI was positively correlated with PT (r = 0.67, P < 0.001) and LL (r = 0.62, P < 0.05). SS was negatively correlated with PT (r = -0.48, P < 0.05) but positively correlated with LL (r = 0.64, P < 0.05). MF rCSA was positively correlated with ES rCSA (r = 0.71, P < 0.05) (Table 5 ). Table 4 Correlation analysis between parameters within the DLIS group PI PT LL SS TK SVA MF rCSA ES rCSA PI 1 PT 0.79* 1 LL 0.06 -0.67 1 SS 0.34 0.34 0.25 1 TK -0.13 -0.01 0.43* 0.23 1 SVA 0.10 0.11 -0.04 0.06 0.32 1 MF rCSA 0.15 -0.16 0.77 0.01 0.83 0.56 1 ES rCSA 0.04 -0.16 0.07 0.34 0.04 -0.08 0.62* 1 Note * Statically significant (P < 0.05) PI: Pelvic Incidence; PT: Pelvic Tilt; LL: Lumbar Lordosis; TK: Thoracic Kyphosis; SS: Sacral Slope; SVA: Sagittal Vertical Axis; MF: Multifidi; ES: Erector Spinae muscle; rCSA: relatively Cross-Sectional Area r = 0 : No linear correlation. |r| < 0.3 : Poor correlation. 0.3 ≤ |r| < 0.5 : Fair correlation. 0.6 ≤ |r| < 0.8 : Moderately strong correlation.0.8 ≤ |r| < 1 : Very strong correlation[ 12 ] Table 5 Correlation analysis between parameters within the L5-IS group PI PT LL SS TK SVA MF rCSA ES rCSA PI 1 PT 0.67* 1 LL 0.62* 0.09 1 SS 0.31 -0.48* 0.64* 1 TK -0.03 -0.12 0.36* 0.36* 1 SVA -0.05 0.20 -0.36 -0.36* 0.02 1 MF rCSA -0.25 0.02 -0.33 -0.01 -0.05 -0.01 1 ES rCSA -0.24 -0.05 -0.19 0.14 0.30 -0.02 0.71* 1 Note * Statically significant (P < 0.05) PI: Pelvic Incidence; PT: Pelvic Tilt; LL: Lumbar Lordosis; TK: Thoracic Kyphosis; SS: Sacral Slope; SVA: Sagittal Vertical Axis; MF: Multifidi; ES: Erector Spinae muscle; rCSA: relatively Cross-Sectional Area r = 0 : No linear correlation. |r| < 0.3 : Poor correlation. 0.3 ≤ |r| < 0.5 : Fair correlation. 0.6 ≤ |r| < 0.8 : Moderately strong correlation.0.8 ≤ |r| < 1 : Very strong correlation.[ 12 ] Multivariate logistic regression identified PI (OR = 1.098, P = 0.002), PT (OR = 2.090, P < 0.001), and SS (OR = 2.014, P < 0.001) as significant predictive factors for DLIS. ROC curve analysis was performed to evaluate the predictive performance of these variables for DLIS. The area under the curve (AUC) was 0.751 for PI, 0.711 for PT, and 0.612 for SS, indicating that PI and PT have good discriminatory power, while SS showed limited predictive value. ( Fig. 4 ). Discussion Differences in Sagittal Plane Parameters Between the Two Groups and Clinical Significance PI, a relatively fixed morphological parameter, is a key indicator of spinal-pelvic sagittal balance [ 6 ].A larger PI suggests that the lumbar spine requires greater lordosis to maintain mechanical balance and stability. An excessively large PI increases shear stress on the lower lumbar spine, heightening the risk of isthmic defects and vertebral slippage[ 13 ]. In this study, the DLIS group had significantly larger PI (60.56 ± 9.50 vs 51.89 ± 9.70, P < 0.001), indicating that individuals with higher PI are more prone to DLIS. This is consistent with previous studies that identified high PI as a significant predictive factor for the occurrence and progression of lumbar isthmic spondylolisthesis. Although no significant difference in LL was found between the two groups (43.00 ± 9.00 vs 39.58 ± 12.83, P = 0.221), the increase in PI suggests potential instability in the lumbosacral region [ 14 ]. The DLIS group also had significantly larger PT (28.33 ± 9.31 vs 20.91 ± 9.70, P = 0.030), indicating that DLIS patients require greater pelvic retroversion to maintain sagittal balance [ 15 , 16 ]. While this compensatory mechanism helps maintain balance, it may alter the loading pattern in the lumbosacral region, leading to increased stress on the lower lumbar spine, potentially accelerating the progression of spondylolisthesis [ 14 ].We hypothesize that high PT reflects both congenital differences and compensatory adaptation in the presence of pathological conditions. Thus, high PT may have both structural and compensatory implications for DLIS. Therefore, the significantly increased PI and PT observed in the DLIS group suggest abnormalities in pelvic morphology and compensatory mechanisms. These alterations not only provide an anatomical basis for the development of DLIS but also offer valuable reference points for assessing the risk of its onset and progression. Based on these findings, we propose a potential pathomechanism for DLIS. In individuals with a high PI, the lumbosacral region experiences increased shear stress, which initially leads to stress fractures and spondylolisthesis at the L5 pars interarticularis. As the L5 vertebra slips forward, the spine’s center of gravity shifts anteriorly. The body responds with biomechanical compensation by increasing pelvic retroversion (elevated PT) and enhancing LL (lumbar extension). Because PI is a fixed anatomical parameter, an increase in PT necessarily reduces the SS, resulting in sacral verticalization and narrowing of the bony space at the lumbosacral junction. Under these biomechanical conditions, excessive lumbar extension imposes sustained vertical compressive stress on the L4 pars interarticularis, forming a stress transmission pattern resembling a “nutcracker”[ 17 ] This ultimately leads to secondary fractures at L4 and the development of DLIS. (Fig. 5 ) Differences in Paraspinal Muscle Area Between the Two Groups and Clinical Significance Both MF rCSA(0.39 ± 0.12 VS 0.49 ± 0.13, P = 0.002) and ES rCSA 0.82 ± 0.31 VS 1.17 ± 0.38, P = 0.001༉were significantly lower in the DLIS group, indicating more severe paraspinal muscle degeneration. Reduction in ES-CSA suggests functional decline, potentially impairing the ability to maintain posture and balance [ 18 ].Weakening of the muscular support system may reduce the capacity of DLIS patients to compensate for spinopelvic abnormalities, thereby increasing the risk of progression or extension of slippage[ 19 ]. Correlation and predictive factors In the DLIS group, PI was highly positively correlated with PT (r = 0.79, P < 0.001), indicating that sagittal balance mainly relies on compensatory pelvic retroversion. On the other hand, LL showed only a weak correlation with TK (r = 0.43) and was not significantly correlated with other sagittal parameters. This further suggests that sagittal imbalance in the DLIS group is primarily compensated by pelvic retroversion (increased PT) rather than adjustments in LL. In the L5-IS group, PI remained positively correlated with PT (r = 0.67, P < 0.05), but it was also significantly correlated with LL (r = 0.62, P < 0.05), suggesting that LL serves as an important compensatory factor for sagittal balance in this group [ 20 ].Furthermore, SS was negatively correlated with PT (r = − 0.48) and positively correlated with LL (r = 0.64), indicating that changes in sacral slope are more closely related to lumbar curvature in the L5-IS group. In summary, sagittal compensation in the DLIS group mainly relies on pelvic retroversion, whereas in the L5-IS group it is achieved through increased lumbar lordosis [ 21 ].This difference suggests that the pathogenesis of DLIS is not only associated with local lumbar imbalance but also involves the interaction between pelvic compensation and overall sagittal alignment. Further logistic regression analysis supported this view: PI (OR = 1.098, P = 0.002), PT (OR = 2.090, P < 0.001), and SS (OR = 2.014, P < 0.001) demonstrated potential as independent predictive factors for DLIS [ 22 ].These parameters, together with paraspinal muscle condition, may interact to influence sagittal balance and contribute to the development of MLIS. Limitations of the Study First, the retrospective nature of the study inherently cannot completely eliminate potential biases. Second, the evaluation of paraspinal muscle degeneration did not include other factors such as fat infiltration. Finally, the lack of long-term follow-up prevents further validation of the impact of sagittal plane parameters and paraspinal muscle degeneration on disease progression and postoperative prognosis. Conclusion Patients with DLIS exhibited larger PI and PT values but smaller MF rCSA and ES rCSA compared with those with L5-IS, suggesting different compensatory mechanisms for sagittal imbalance. Larger PI and PT demonstrated potential as independent predictive factors for DLIS. Declarations Data availability All data generated or analyzed during this study are included in this published article. Competing interests The authors declare that they have no competing interests. Author contributions Y.X.L. and Y.C. were responsible for the study concept and writing the article. X.Y.F. and Y.X.L.was responsible for reviewing and writing the article. All the authors contributed to the study conception and design. Material preparation, literature review, data collection, and quality assessment were performed by Q.W. Statistical analysis was performed by Y.X.L. and Y.C. share the first authorship, due to equal contributions. The first draft of the manuscript was written by Q.W.. and J.Y.; Y.X.L. and all the authors commented on previous versions of the manuscript. All the authors read and approved the final manuscript. Consent to Participate declarations Informed consent was obtained from all individual participants included in the study. Ethics approval This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of University the Affiliated Hospital of Southwest Medical University (Date September 15, 2025/ No. KY2025486) Consent to publish Not applicable. Data availability The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request. Funding Statement This research was funded by the Project of Southwest Medical University (grant number: 2024LCYXZX36) and the Project of Sichuan Provincial Department of Science and Technology (grant number: 2023YFS0097). 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8025252","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":551799331,"identity":"c87ee37d-59e8-4bf2-b052-8f117fd74c6d","order_by":0,"name":"YuanXuan Li","email":"","orcid":"","institution":"The Affifiliated Hospital of Southwest Medical University","correspondingAuthor":false,"prefix":"","firstName":"YuanXuan","middleName":"","lastName":"Li","suffix":""},{"id":551799332,"identity":"53d4bcf6-7131-41f8-9e36-ef18eee19131","order_by":1,"name":"Yao Chen","email":"","orcid":"","institution":"The Affifiliated Hospital of Southwest Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yao","middleName":"","lastName":"Chen","suffix":""},{"id":551799333,"identity":"7df7bafc-05c5-4758-9a11-0981c4828d5a","order_by":2,"name":"XinWei Fu","email":"","orcid":"","institution":"The Affifiliated Hospital of Southwest Medical University","correspondingAuthor":false,"prefix":"","firstName":"XinWei","middleName":"","lastName":"Fu","suffix":""},{"id":551799334,"identity":"a831cbab-827b-427d-a81a-6b123284bf5f","order_by":3,"name":"ChaoHua Yang","email":"","orcid":"","institution":"The Affifiliated Hospital of Southwest Medical University","correspondingAuthor":false,"prefix":"","firstName":"ChaoHua","middleName":"","lastName":"Yang","suffix":""},{"id":551799335,"identity":"b69e1264-b5f6-4a7b-9393-9cc67235e3f7","order_by":4,"name":"Qing Wang","email":"","orcid":"","institution":"The Affifiliated Hospital of Southwest Medical University","correspondingAuthor":false,"prefix":"","firstName":"Qing","middleName":"","lastName":"Wang","suffix":""},{"id":551799336,"identity":"7015a22b-46e0-4818-9c1f-62c11070bbff","order_by":5,"name":"Jin Yang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBElEQVRIie3RPUvDQBjA8ecIXJecWa8UGj/CQaAu4mfJUejsrmBs4JmEzn4Lp+B45SC3FLNGujQIcVWculgvpRUccl0d7r/dy4/jeAB8vn+ZAkgBxjQg980WtcziquRwq0+SJBoEecLwXWY8nHEo306+JR8XAxwR3HVkwsn8q/eqWJp20zxfkidN8Ibg+kAyB1GrCyFXs0BY8rotLIkfOrJ2EcolatqRmhW/r7iIaS3ZhR25ZoU+kspB1MQSxYc5QWDfRzI3vWS4/wtORRSQfMRedEJ5OBVp2U/OatPaCV7dYWSaTzvKcRRXy82HY5TntaJ/d/bLtBcAxIuMOo59Pp/PZ/sB6fJoIhN9wJgAAAAASUVORK5CYII=","orcid":"","institution":"The Affifiliated Hospital of Southwest Medical University","correspondingAuthor":true,"prefix":"","firstName":"Jin","middleName":"","lastName":"Yang","suffix":""}],"badges":[],"createdAt":"2025-11-04 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14:25:29","extension":"png","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":177186,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-8025252/v1/962a8b2430884edf43b6289a.png"},{"id":97368185,"identity":"1a8d078c-a4b5-4d52-bfe2-6fce5dbc57e1","added_by":"auto","created_at":"2025-12-03 16:21:45","extension":"xml","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":92762,"visible":true,"origin":"","legend":"","description":"","filename":"30ea52d82d7a4bbc82f5ad59c22f80171structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8025252/v1/31bb9a50cdc11beab9a10ab1.xml"},{"id":97264938,"identity":"a1bbe469-96d5-427f-95c3-257ecfa9f0c7","added_by":"auto","created_at":"2025-12-02 14:25:29","extension":"html","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":99532,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8025252/v1/100bd3cc0554120f6031d968.html"},{"id":97368611,"identity":"cd38195b-8c7b-44c9-8813-eb160a3f3abc","added_by":"auto","created_at":"2025-12-03 16:22:33","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":290261,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eStudy flow diagram\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8025252/v1/68a18a5f4a888641e030c9c3.jpeg"},{"id":97264939,"identity":"f0a9531c-5175-4db4-801c-258a2068b09f","added_by":"auto","created_at":"2025-12-02 14:25:30","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":581390,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eImage Measurement Methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePI: Pelvic Incidence; PT: Pelvic Tilt; LL:Lumbar Lordosis; TK: Thoracic Kyphosis; SS: Sacral Slope; SVA: Sagittal Vertical Axis; Pfirrmann classification[10]; pLnL: partial Lumbar Lordosis ( n represents a specific segment)\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8025252/v1/4db21e016aee8a58b825d8ff.jpeg"},{"id":97264928,"identity":"68d71a43-1b05-4d4f-98ca-a48465516d71","added_by":"auto","created_at":"2025-12-02 14:25:29","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":483999,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eImage Measurement Methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eVB: Vertebral Body; MF: Multifidi; ES: Erector Spinae muscle\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8025252/v1/158ef4a7cda741730837c6d8.jpeg"},{"id":97368573,"identity":"2fcb4ebb-07a6-49d9-ba37-595f7a6e2217","added_by":"auto","created_at":"2025-12-03 16:22:29","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":258143,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eROC curve\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePT: Pelvic Tilt; LL: Lumbar Lordosis; SS: Sacral Slope; AUC: The area under the curve\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8025252/v1/60584c3e24555d09252dd77b.jpeg"},{"id":97367473,"identity":"7cec1cee-5f20-492a-aa90-dccf2455f7b9","added_by":"auto","created_at":"2025-12-03 16:18:54","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":695039,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSchematic Diagram\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGL: Gravity Line PT: Pelvic Tilt; \u0026nbsp;\u0026nbsp;LL: Lumbar Lordosis; SS: Sacral Slope;\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-8025252/v1/d811955c6158037af1e6f20b.png"},{"id":97664551,"identity":"ada30f87-74b3-4f88-a7f0-93bd281241e4","added_by":"auto","created_at":"2025-12-08 09:09:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3070385,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8025252/v1/cce200dd-6f48-4211-b225-906c23f81b2b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Imaging-Based Evaluation of Predictive Factors in Single- and Double-Level Isthmic Spondylolisthesis: A Comparative and Correlational Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIsthmic spondylolisthesis (IS) is a common form of lumbar spondylolisthesis, most often occurring at the L5 vertebra as single-level isthmic spondylolisthesis (L5-IS) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].Multi-level isthmic spondylolisthesis (MLIS) has a relatively low incidence and is often overlooked in clinical practice. It typically occurs at the L4 and L5 levels, though it may also affect the L3-L5 or L2-L5 segments [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].Although extensive research has been conducted on the etiology, pathophysiology, progression, diagnosis, and treatment of L5-IS[\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e],studies on MLIS are scarce, and the differences between the two remain unclear. These differences could significantly affect the understanding, evaluation, treatment planning, prognosis, and quality of life for MLIS patients.\u003c/p\u003e\u003cp\u003eSpinal-pelvic balance and sagittal plane parameters are key factors in studying lumbar spondylolisthesis. Intervertebral disc degeneration and paraspinal muscle function also play critical roles in the development and progression of lumbar spondylolisthesis [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].The association of these factors with MLIS and their differences from L5-IS remain pressing clinical questions. Therefore, investigating the role of these factors in MLIS is crucial for enhancing its diagnosis and treatment.\u003c/p\u003e\u003cp\u003eThis study focuses on patients with Double-level isthmic spondylolisthesis (DLIS) as part of MLIS, comparing them with the L5-IS group. A retrospective analysis will compare sagittal parameters, intervertebral disc degeneration, and paraspinal muscle function between the two groups, using correlation analysis to identify predictive factors for DLIS occurrence.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eA retrospective analysis of clinical and imaging data from patients diagnosed with IS between January 2018 and April 2025 in our department. The inclusion criteria were: (1)Age\u0026thinsp;\u0026gt;\u0026thinsp;18 years at admission; ༈2༉ Imaging meets diagnostic criteria for DLIS with a slip degree\u0026thinsp;\u0026lt;\u0026thinsp;50%; ༈3༉ No other spinal or orthopedic conditions affecting the results. The exclusion criteria were: ༈1༉ History of spinal surgery, trauma, or infection; ༈2༉Presence of spinal tumors, fractures, scoliosis, or lumbosacral transitional vertebrae; ༈3༉ Slip degree\u0026thinsp;\u0026gt;\u0026thinsp;50%; ༈4༉Simple isthmic defect; ༈5༉ IS involving\u0026thinsp;\u0026gt;\u0026thinsp;two segments. Based on these criteria, 32 cases of DLIS and 100 cases of L5-IS were included. After Propensity Score Matching (PSM)[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], 32 patients from each group were included for analysis. The study was approved by the local ethics committee \u0026ndash; due to its retrospective nature, informed consent was not deemed necessary (No: KY2025486).༈Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e༉\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eStudy Data\u003c/p\u003e\u003cp\u003eBaseline data included gender, age, body mass index (BMI), disease duration, diabetes, smoking history, Oswestry Disability Index (ODI) score, Low Back Pain Visual Analogue Scale (LBP-VAS), and Leg Pain Visual Analogue Scale (LP-VAS). Imaging data included preoperative X-rays of the entire spine or lumbar spine (including both hips) in the standing lateral position, as well as Whole Spine Magnetic Resonance Imaging (WS-MRI), measuring the following sagittal parameters: Pelvic Incidence (PI), Pelvic Tilt (PT), Lumbar Lordosis (LL), Thoracic Kyphosis (TK), Sacral Slope (SS), Sagittal Vertical Axis (SVA), Area of Multifidi (A-MF), and Multifidus Cross-Sectional Area (MF-CSA), Erector Spinae Cross-Sectional Area (ES-CSA), and Vertebral Body Cross-Sectional Area (VB-CSA). Relative cross-sectional area (rCSA) was defined as the ratio of muscle CSA to the corresponding vertebral body CSA, reducing the influence of individual body size, weight, and height[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. And degree of disc degeneration in the affected segments (Pfirrmann grading) were also assessed. In this study, the angle between the upper and lower endplates of adjacent vertebrae was defined as a study unit, with its Partial Lumbar Lordosis angle (partial Lumbar Lordosis, pLnL) measured (where 'n' represents a specific segment, e.g. pL4L for L4). The segment with the most severe disc degeneration in the DLIS group was used to assess intervertebral disc degeneration. (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)༈Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e༉\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003ePropensity score matching (PSM) was used to minimize selection bias between the groups. A caliper width of 0.2 was applied, and one-to-one nearest neighbor matching (greedy algorithm, without replacement) was performed using the \u0026ldquo;MatchIt\u0026rdquo; package in R (version 4.0.4, R Project for Statistical Computing, Vienna, Austria), as described by Austin[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Continuous variables were tested for normality. Normally distributed data were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, while categorical and ordinal data were expressed as frequencies or percentages. Student\u0026rsquo;s t-test were used for normally distributed continuous variables, and nonparametric tests were applied for non-normally distributed variables. The chi-square test was used for categorical variables, and the rank-sum test was applied for ordinal variables. Pearson correlation analysis was performed for normally distributed variables, whereas Spearman correlation was used for non-normally distributed or ordinal variables. Multivariate logistic regression analysis was conducted with PI, PT, LL, SS, TK, SVA, MF rCSA, and ES rCSA as covariates to evaluate predictive factors for DLIS. All statistical analyses were performed using SPSS version 24.0 (IBM, Chicago, IL, USA). A P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 64 subjects participated in the study, with 32 in the DLIS group and 32 in the L5-IS group. No statistically significant differences were found between the two groups in gender distribution, BMI, ODI, disease duration, and LBP-VAS and LP-VAS (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). No significant differences were observed in pLnL between the two groups (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of data between the two groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDLIS Group(n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eL5-IS Group(n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eT/χ2 value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge(years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e61.97\u0026thinsp;\u0026plusmn;\u0026thinsp;9.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57.63\u0026thinsp;\u0026plusmn;\u0026thinsp;10.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.495\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.115\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender(M/%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15(46.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13(40.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.675\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.071\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI(kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23.86\u0026thinsp;\u0026plusmn;\u0026thinsp;4.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24.81\u0026thinsp;\u0026plusmn;\u0026thinsp;3.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-1.683\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.947\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuration of the disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12.10\u0026thinsp;\u0026plusmn;\u0026thinsp;0.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.96\u0026thinsp;\u0026plusmn;\u0026thinsp;0.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.654\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.513\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmoking(Y/%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7(21.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5(15.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.245\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.723\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiabetes(Y/%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4(12.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5(15.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.438\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.612\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eODI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e64.28\u0026thinsp;\u0026plusmn;\u0026thinsp;4.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e65.68\u0026thinsp;\u0026plusmn;\u0026thinsp;3.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-1.241\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.225\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLBP-VAS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.48\u0026thinsp;\u0026plusmn;\u0026thinsp;0.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.84\u0026thinsp;\u0026plusmn;\u0026thinsp;0.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-1.652\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.105\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLP-VAS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.48\u0026thinsp;\u0026plusmn;\u0026thinsp;0.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.84\u0026thinsp;\u0026plusmn;\u0026thinsp;0.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-1.652\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.102\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePfirrmann classification\u003c/p\u003e\u003cp\u003eIII\u003c/p\u003e\u003cp\u003eIV\u003c/p\u003e\u003cp\u003eV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003cp\u003e10\u003c/p\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003cp\u003e9\u003c/p\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-2.531\u003c/p\u003e\u003cp\u003e-3.257\u003c/p\u003e\u003cp\u003e-1.576\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.162\u003c/p\u003e\u003cp\u003e0.731\u003c/p\u003e\u003cp\u003e0.132\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eNote Data are presented as number of patients or mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD; DLIS: Double-level Isthmic Spondylolisthesis; L5-IS: L5 Isthmic Spondylolisthesis; M: Male; BMI: Body Mass Index; Y: Yes; ODI: Oswestry Disability Index; LBP-VAS: Low Back Pain on Visual Analogue Scale; LP-VAS: Leg Pain on Visual Analogue Scale; Pfirrmann classification[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of partial lumbar lordosis between the two groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDLIS Group(n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eL5-IS Group(n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eT value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epL\u003csub\u003e1\u003c/sub\u003eL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e5.25\u0026thinsp;\u0026plusmn;\u0026thinsp;0.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e4.54\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.046\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.300\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epL\u003csub\u003e2\u003c/sub\u003eL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e6.30\u0026thinsp;\u0026plusmn;\u0026thinsp;0.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e7.35\u0026thinsp;\u0026plusmn;\u0026thinsp;1.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.742\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.462\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epL\u003csub\u003e3\u003c/sub\u003eL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e11.29\u0026thinsp;\u0026plusmn;\u0026thinsp;0.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e9.57\u0026thinsp;\u0026plusmn;\u0026thinsp;0.66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.904\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.062\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epL\u003csub\u003e4\u003c/sub\u003eL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e15.09\u0026thinsp;\u0026plusmn;\u0026thinsp;3.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e14.07\u0026thinsp;\u0026plusmn;\u0026thinsp;0.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.314\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.756\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epL\u003csub\u003e5\u003c/sub\u003eL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e15.01\u0026thinsp;\u0026plusmn;\u0026thinsp;0.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e17.77\u0026thinsp;\u0026plusmn;\u0026thinsp;1.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-1.970\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.053\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eNote pL\u003csub\u003en\u003c/sub\u003eL partial Lumbar Lordosis( n represents a specific segment); DLIS Double-level Isthmic Spondylolisthesis; L5-IS L5 Isthmic Spondylolisthesis\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe DLIS group exhibited significantly larger PI (60.56\u0026thinsp;\u0026plusmn;\u0026thinsp;9.50 vs. 51.89\u0026thinsp;\u0026plusmn;\u0026thinsp;9.70, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and PT (28.33\u0026thinsp;\u0026plusmn;\u0026thinsp;9.31 vs. 20.91\u0026thinsp;\u0026plusmn;\u0026thinsp;9.70, P\u0026thinsp;=\u0026thinsp;0.03), but significantly smaller MF rCSA (0.39\u0026thinsp;\u0026plusmn;\u0026thinsp;0.12 vs. 0.49\u0026thinsp;\u0026plusmn;\u0026thinsp;0.13, P\u0026thinsp;=\u0026thinsp;0.002) and ES rCSA (0.82\u0026thinsp;\u0026plusmn;\u0026thinsp;0.31 vs. 1.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.38, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating more severe paraspinal muscle degeneration in the DLIS group. No significant differences were found in other parameters (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of imaging parameters between the two groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDLIS Group(n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eL5-IS Group(n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eT value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePI(\u0026deg;)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e60.56\u0026thinsp;\u0026plusmn;\u0026thinsp;9.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e51.89\u0026thinsp;\u0026plusmn;\u0026thinsp;9.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.619\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePT(\u0026deg;)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e28.33\u0026thinsp;\u0026plusmn;\u0026thinsp;9.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e20.91\u0026thinsp;\u0026plusmn;\u0026thinsp;9.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.120\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.030\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLL(\u0026deg;)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e43.00\u0026thinsp;\u0026plusmn;\u0026thinsp;9.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e39.58\u0026thinsp;\u0026plusmn;\u0026thinsp;12.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.239\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.221\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSS(\u0026deg;)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e34.63\u0026thinsp;\u0026plusmn;\u0026thinsp;6.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e31.33\u0026thinsp;\u0026plusmn;\u0026thinsp;7.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.765\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.083\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTK(\u0026deg;)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e27.63\u0026thinsp;\u0026plusmn;\u0026thinsp;6.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e31.08\u0026thinsp;\u0026plusmn;\u0026thinsp;9.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-1.714\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.091\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSVA(cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e3.17\u0026thinsp;\u0026plusmn;\u0026thinsp;1.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e3.62\u0026thinsp;\u0026plusmn;\u0026thinsp;1.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-1.435\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.156\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMF CSA(mm\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e694.38\u0026thinsp;\u0026plusmn;\u0026thinsp;160.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e701.71\u0026thinsp;\u0026plusmn;\u0026thinsp;175.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.174\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.862\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eES CSA(mm\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e1420.76\u0026thinsp;\u0026plusmn;\u0026thinsp;309.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e1650.32\u0026thinsp;\u0026plusmn;\u0026thinsp;452.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-2.368\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.021\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMF rCSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e0.39\u0026thinsp;\u0026plusmn;\u0026thinsp;0.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e0.49\u0026thinsp;\u0026plusmn;\u0026thinsp;0.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-3.237\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eES rCSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e0.82\u0026thinsp;\u0026plusmn;\u0026thinsp;0.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e1.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-4.057\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eNote DLIS Double-level Isthmic Spondylolisthesis; L5-IS L5 Isthmic Spondylolisthesis; PI: Pelvic Incidence; PT: Pelvic Tilt; LL: Lumbar Lordosis; TK: Thoracic Kyphosis; SS: Sacral Slope; SVA: Sagittal Vertical Axis; MF CSA: Multifidi Cross-Sectional Area; ES CSA: Erector Spinae Muscle Cross-Sectional Area; MF: Multifidi; ES: Erector Spinae muscle; rCSA: relatively Cross-Sectional Area; mm: millimeter;\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eCorrelation analysis revealed that in the DLIS group, PI was strongly positively correlated with PT (r\u0026thinsp;=\u0026thinsp;0.792, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). MF rCSA was positively correlated with ES rCSA (r\u0026thinsp;=\u0026thinsp;0.62, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and LL showed a weak correlation with TK (r\u0026thinsp;=\u0026thinsp;0.43, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). In the L5-IS group, PI was positively correlated with PT (r\u0026thinsp;=\u0026thinsp;0.67, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and LL (r\u0026thinsp;=\u0026thinsp;0.62, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). SS was negatively correlated with PT (r = -0.48, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) but positively correlated with LL (r\u0026thinsp;=\u0026thinsp;0.64, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). MF rCSA was positively correlated with ES rCSA (r\u0026thinsp;=\u0026thinsp;0.71, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCorrelation analysis between parameters within the DLIS group\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePT\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTK\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eSVA\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eMF rCSA\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eES rCSA\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.79*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTK\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.43*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSVA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMF rCSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eES rCSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.62*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003eNote * Statically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) PI: Pelvic Incidence; PT: Pelvic Tilt; LL: Lumbar Lordosis; TK: Thoracic Kyphosis; SS: Sacral Slope; SVA: Sagittal Vertical Axis; MF: Multifidi; ES: Erector Spinae muscle; rCSA: relatively Cross-Sectional Area\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003er\u0026thinsp;=\u0026thinsp;0 : No linear correlation. |r| \u0026lt; 0.3 : Poor correlation. 0.3 \u0026le; |r| \u0026lt; 0.5 : Fair correlation. 0.6 \u0026le; |r| \u0026lt; 0.8 : Moderately strong correlation.0.8 \u0026le; |r| \u0026lt; 1 : Very strong correlation[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCorrelation analysis between parameters within the L5-IS group\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePT\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTK\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eSVA\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eMF rCSA\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eES rCSA\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.67*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.62*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.48*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.64*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTK\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.36*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.36*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSVA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.36*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMF rCSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eES rCSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.71*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003eNote * Statically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) PI: Pelvic Incidence; PT: Pelvic Tilt; LL: Lumbar Lordosis; TK: Thoracic Kyphosis; SS: Sacral Slope; SVA: Sagittal Vertical Axis; MF: Multifidi; ES: Erector Spinae muscle; rCSA: relatively Cross-Sectional Area\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003er\u0026thinsp;=\u0026thinsp;0 : No linear correlation. |r| \u0026lt; 0.3 : Poor correlation. 0.3 \u0026le; |r| \u0026lt; 0.5 : Fair correlation. 0.6 \u0026le; |r| \u0026lt; 0.8 : Moderately strong correlation.0.8 \u0026le; |r| \u0026lt; 1 : Very strong correlation.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMultivariate logistic regression identified PI (OR\u0026thinsp;=\u0026thinsp;1.098, P\u0026thinsp;=\u0026thinsp;0.002), PT (OR\u0026thinsp;=\u0026thinsp;2.090, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and SS (OR\u0026thinsp;=\u0026thinsp;2.014, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) as significant predictive factors for DLIS. ROC curve analysis was performed to evaluate the predictive performance of these variables for DLIS. The area under the curve (AUC) was 0.751 for PI, 0.711 for PT, and 0.612 for SS, indicating that PI and PT have good discriminatory power, while SS showed limited predictive value. ( Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eDifferences in Sagittal Plane Parameters Between the Two Groups and Clinical Significance\u003c/h2\u003e\u003cp\u003ePI, a relatively fixed morphological parameter, is a key indicator of spinal-pelvic sagittal balance [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].A larger PI suggests that the lumbar spine requires greater lordosis to maintain mechanical balance and stability. An excessively large PI increases shear stress on the lower lumbar spine, heightening the risk of isthmic defects and vertebral slippage[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In this study, the DLIS group had significantly larger PI (60.56\u0026thinsp;\u0026plusmn;\u0026thinsp;9.50 vs 51.89\u0026thinsp;\u0026plusmn;\u0026thinsp;9.70, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating that individuals with higher PI are more prone to DLIS. This is consistent with previous studies that identified high PI as a significant predictive factor for the occurrence and progression of lumbar isthmic spondylolisthesis. Although no significant difference in LL was found between the two groups (43.00\u0026thinsp;\u0026plusmn;\u0026thinsp;9.00 vs 39.58\u0026thinsp;\u0026plusmn;\u0026thinsp;12.83, P\u0026thinsp;=\u0026thinsp;0.221), the increase in PI suggests potential instability in the lumbosacral region [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The DLIS group also had significantly larger PT (28.33\u0026thinsp;\u0026plusmn;\u0026thinsp;9.31 vs 20.91\u0026thinsp;\u0026plusmn;\u0026thinsp;9.70, P\u0026thinsp;=\u0026thinsp;0.030), indicating that DLIS patients require greater pelvic retroversion to maintain sagittal balance [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. While this compensatory mechanism helps maintain balance, it may alter the loading pattern in the lumbosacral region, leading to increased stress on the lower lumbar spine, potentially accelerating the progression of spondylolisthesis [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].We hypothesize that high PT reflects both congenital differences and compensatory adaptation in the presence of pathological conditions. Thus, high PT may have both structural and compensatory implications for DLIS. Therefore, the significantly increased PI and PT observed in the DLIS group suggest abnormalities in pelvic morphology and compensatory mechanisms. These alterations not only provide an anatomical basis for the development of DLIS but also offer valuable reference points for assessing the risk of its onset and progression. Based on these findings, we propose a potential pathomechanism for DLIS. In individuals with a high PI, the lumbosacral region experiences increased shear stress, which initially leads to stress fractures and spondylolisthesis at the L5 pars interarticularis. As the L5 vertebra slips forward, the spine\u0026rsquo;s center of gravity shifts anteriorly. The body responds with biomechanical compensation by increasing pelvic retroversion (elevated PT) and enhancing LL (lumbar extension). Because PI is a fixed anatomical parameter, an increase in PT necessarily reduces the SS, resulting in sacral verticalization and narrowing of the bony space at the lumbosacral junction. Under these biomechanical conditions, excessive lumbar extension imposes sustained vertical compressive stress on the L4 pars interarticularis, forming a stress transmission pattern resembling a \u0026ldquo;nutcracker\u0026rdquo;[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] This ultimately leads to secondary fractures at L4 and the development of DLIS. (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eDifferences in Paraspinal Muscle Area Between the Two Groups and Clinical Significance\u003c/h2\u003e\u003cp\u003eBoth MF rCSA(0.39\u0026thinsp;\u0026plusmn;\u0026thinsp;0.12 VS 0.49\u0026thinsp;\u0026plusmn;\u0026thinsp;0.13, P\u0026thinsp;=\u0026thinsp;0.002) and ES rCSA 0.82\u0026thinsp;\u0026plusmn;\u0026thinsp;0.31 VS 1.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.38, P\u0026thinsp;=\u0026thinsp;0.001༉were significantly lower in the DLIS group, indicating more severe paraspinal muscle degeneration. Reduction in ES-CSA suggests functional decline, potentially impairing the ability to maintain posture and balance [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].Weakening of the muscular support system may reduce the capacity of DLIS patients to compensate for spinopelvic abnormalities, thereby increasing the risk of progression or extension of slippage[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eCorrelation and predictive factors\u003c/h3\u003e\n\u003cp\u003eIn the DLIS group, PI was highly positively correlated with PT (r\u0026thinsp;=\u0026thinsp;0.79, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating that sagittal balance mainly relies on compensatory pelvic retroversion. On the other hand, LL showed only a weak correlation with TK (r\u0026thinsp;=\u0026thinsp;0.43) and was not significantly correlated with other sagittal parameters. This further suggests that sagittal imbalance in the DLIS group is primarily compensated by pelvic retroversion (increased PT) rather than adjustments in LL.\u003c/p\u003e\u003cp\u003eIn the L5-IS group, PI remained positively correlated with PT (r\u0026thinsp;=\u0026thinsp;0.67, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), but it was also significantly correlated with LL (r\u0026thinsp;=\u0026thinsp;0.62, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), suggesting that LL serves as an important compensatory factor for sagittal balance in this group [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].Furthermore, SS was negatively correlated with PT (r = \u0026minus;\u0026thinsp;0.48) and positively correlated with LL (r\u0026thinsp;=\u0026thinsp;0.64), indicating that changes in sacral slope are more closely related to lumbar curvature in the L5-IS group.\u003c/p\u003e\u003cp\u003eIn summary, sagittal compensation in the DLIS group mainly relies on pelvic retroversion, whereas in the L5-IS group it is achieved through increased lumbar lordosis [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].This difference suggests that the pathogenesis of DLIS is not only associated with local lumbar imbalance but also involves the interaction between pelvic compensation and overall sagittal alignment. Further logistic regression analysis supported this view: PI (OR\u0026thinsp;=\u0026thinsp;1.098, P\u0026thinsp;=\u0026thinsp;0.002), PT (OR\u0026thinsp;=\u0026thinsp;2.090, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and SS (OR\u0026thinsp;=\u0026thinsp;2.014, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) demonstrated potential as independent predictive factors for DLIS [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].These parameters, together with paraspinal muscle condition, may interact to influence sagittal balance and contribute to the development of MLIS.\u003c/p\u003e\n\u003ch3\u003eLimitations of the Study\u003c/h3\u003e\n\u003cp\u003eFirst, the retrospective nature of the study inherently cannot completely eliminate potential biases. Second, the evaluation of paraspinal muscle degeneration did not include other factors such as fat infiltration. Finally, the lack of long-term follow-up prevents further validation of the impact of sagittal plane parameters and paraspinal muscle degeneration on disease progression and postoperative prognosis.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePatients with DLIS exhibited larger PI and PT values but smaller MF rCSA and ES rCSA compared with those with L5-IS, suggesting different compensatory mechanisms for sagittal imbalance. Larger PI and PT demonstrated potential as independent predictive factors for DLIS.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eY.X.L. and Y.C. were responsible for the study concept and writing the article. X.Y.F. and Y.X.L.was responsible for reviewing and writing the article. All the authors contributed to the study conception and design. Material preparation, literature review, data collection, and quality assessment were performed by Q.W. Statistical analysis was performed by Y.X.L. \u0026nbsp;and \u0026nbsp;Y.C. share the first authorship, due to equal contributions. The first draft of the manuscript was written by Q.W.. and J.Y.; Y.X.L. and all the authors commented on previous versions of the manuscript. All the authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of University the Affiliated Hospital of Southwest Medical University (Date September 15, 2025/ No. KY2025486)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eStatement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded by the Project of Southwest Medical University (grant number: 2024LCYXZX36) and the Project of Sichuan Provincial Department of Science and Technology (grant number: 2023YFS0097).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlomari S, Judy B, Sacino AN, et al. 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J Bone Joint Surg Am. 2005;87(2):260\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2106/JBJS.D.02043\u003c/span\u003e\u003cspan address=\"10.2106/JBJS.D.02043\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Double-level isthmic spondylolisthesis, L5 isthmic spondylolisthesis, sagittal alignment parameters, disc degeneration, paraspinal muscles, predictive factors, propensity score matching","lastPublishedDoi":"10.21203/rs.3.rs-8025252/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8025252/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e\u003cp\u003eTo compare sagittal alignment, disc degeneration, and paraspinal muscle status between patients with single-level L5 isthmic spondylolisthesis (L5-IS) and double-level isthmic spondylolisthesis (DLIS), and to evaluate predictive factors for DLIS.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eSagittal parameters including pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), and lumbar lordosis (LL), as well as the cross-sectional areas of multifidus (MF CSA) and erector spinae (ES CSA), were measured. Comparative analysis, correlation analysis, and multivariate logistic regression were conducted.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA total of 64 patients were included: 32 with DLIS and 32 with L5-IS. The DLIS group showed higher PI (60.56\u0026thinsp;\u0026plusmn;\u0026thinsp;9.50 vs. 51.89\u0026thinsp;\u0026plusmn;\u0026thinsp;9.70, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and PT (28.33\u0026thinsp;\u0026plusmn;\u0026thinsp;9.31 vs. 20.91\u0026thinsp;\u0026plusmn;\u0026thinsp;9.70, P\u0026thinsp;=\u0026thinsp;0.03), but smaller MF-CSA (0.39\u0026thinsp;\u0026plusmn;\u0026thinsp;0.12 vs. 0.49\u0026thinsp;\u0026plusmn;\u0026thinsp;0.13, P\u0026thinsp;=\u0026thinsp;0.002) and ES-CSA (0.82\u0026thinsp;\u0026plusmn;\u0026thinsp;0.31 vs. 1.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.38, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). PI and PT were strongly correlated in both groups. Logistic regression identified increased PI (OR\u0026thinsp;=\u0026thinsp;1.098), PT (OR\u0026thinsp;=\u0026thinsp;2.090), and SS (OR\u0026thinsp;=\u0026thinsp;2.014) as potential predictive factors. Receiver Operating Characteristic (ROC) curve analysis showed acceptable predictive performance for PI (AUC\u0026thinsp;=\u0026thinsp;0.751) and PT (AUC\u0026thinsp;=\u0026thinsp;0.711), while SS had limited value (AUC\u0026thinsp;=\u0026thinsp;0.612).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eDLIS patients exhibit greater pelvic parameters and paraspinal muscle atrophy. PI and PT may have predictive value for DLIS.\u003c/p\u003e","manuscriptTitle":"Imaging-Based Evaluation of Predictive Factors in Single- and Double-Level Isthmic Spondylolisthesis: A Comparative and Correlational Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-02 14:25:24","doi":"10.21203/rs.3.rs-8025252/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-12-14T06:36:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-05T02:56:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"12456383726202241801323592949014884811","date":"2025-12-04T12:27:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"144101545450979686545313822020874880468","date":"2025-12-04T06:08:03+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-27T13:50:15+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-07T08:11:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-06T08:54:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-06T08:49:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2025-11-04T06:35:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9bf19e66-fd3f-4038-8750-3389437acef3","owner":[],"postedDate":"December 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-02T14:25:24+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-02 14:25:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8025252","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8025252","identity":"rs-8025252","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}