Systematic review and meta-Analysis.To identify risk factors for postoperative coronal malalignment (CM) and evaluate its impact on clinical outcomes in patients with degenerative lumbar scoliosis (DLS).Postoperative CM is a common complication after DLS surgery, with an incidence ranging from 20.7% to 38.9%. Identifying its risk factors and impact on surgical outcomes may enhance understanding of the condition and help optimize clinical management strategies.This systematic review was conducted in accordance with the PRISMA guidelines. Relevant studies were retrieved from PubMed, Embase, Scopus, Cochrane Library, and ClinicalTrials.gov. The inclusion criteria were: (1) comparative studies analyzing CM versus non-CM in DLS patients, (2) outcomes reported including demographic data, surgical details, radiographic parameters, and patients-reported outcomes, and (3) observational studies published in English from the inception of the databases to January 2024.Seven studies with a total of 617 patients (191 CM, 426 non-CM) were included. Compared to the non-CM group, patients in the CM group had a higher proportion of females (P=0.03), larger major Cobb angle (P=0.005), greater LS curve Cobb angle (P<0.001), increased L4 tilt angle (P=0.01), L5 tilt angle (P<0.001), and AVT (P<0.001) preoperatively. Postoperatively, CM patients showed higher residual LS curve Cobb angle (P=0.02), L4 tilt angle (P=0.04), and L5 tilt angle (P<0.001), as well as a lower LS curve Cobb angle correction rate (P=0.005). Additionally, the CM group exhibited higher ODI score (P=0.003).Female sex, more severe preoperative coronal deformity, and insufficient correction of the lumbosacral curve are significant factors for postoperative CM following DLS surgery. The presence of CM is associated with diminished functional improvement after surgery.Copyright © 2025 Wolters Kluwer Health, Inc. All rights reserved.