Association Between Lumbosacral Transitional Vertebrae and Spondylolisthesis: A Systematic Review and Meta-Analysis

Lumbosacral transitional vertebrae (LSTV) are common congenital spinal anomalies that may redistribute mechanical loads to adjacent segments. This study aims to provide a comprehensive, quantitative synthesis of the relationship between LSTV & the prevalence, anatomical distribution, and severity of lumbar spondylolisthesis. A systematic review and meta-analysis was conducted according to PRISMA 2020 guidelines. PubMed, Scopus, and Web of Science were searched through November 2025. Studies comparing adult individuals with LSTV to those without were included. Risk of bias was assessed using ROBINS-I. Random-effects meta-analysis was used to calculate pooled odds ratios (OR) for prevalence and distribution, and mean differences for slip severity. Twelve retrospective cohort studies (n = 3929) were included. LSTV was not associated with an increased overall prevalence of degenerative spondylolisthesis (OR 1.28; 95% CI 0.86-1.91; p = 0.22). However, LSTV significantly altered the level of slippage. Patients with LSTV demonstrated strongly increased odds of spondylolisthesis at L4-L5 (OR 13.78; 95% CI 4.30-44.18; p < 0.0001) and a significant protective effect at L5-S1 (OR 0.07; 95% CI 0.02-0.23; p < 0.0001). No significant difference in slip severity was observed in pooled analyses (p = 0.31). LSTV does not increase the overall risk of spondylolisthesis but acts as a biomechanical modifier that markedly redistributes pathology. It protects the transitional segment while shifting mechanical stress and instability to the cranial adjacent level (L4-L5).