inverted Napoleon hat sign

The inverted Napoleon hat sign is a radiologic sign seen on the frontal pelvic or lumbar radiograph at the level of the 5 lumbar vertebra and the sacrum.

It is seen when there is bilateral spondylolysis with marked anterolisthesis of L5 on S1 or marked exaggeration of the normal lordosis at the lumbosacral junction. Spondylolysis resulting in this degree of spondylolisthesis is more often congenital and/or traumatic in origin and less often degenerative.

The "brim" of hat is formed by the caudal translation of the transverse processes and the "dome" of hat is formed by the body of L5.

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