Lumbosacral spondylolisthesis is a frequently encountered pathology with high-grade spondylolisthesis being the least common. A circumferential construct is usually the preferred treatment as these can resist the shearing forces present at L5-S1. However, the severity of the slip, sacral inclination, and the slip angle may make a traditional anterior approach difficult to achieve. In this case series, we present three patients with axial back pain that were treated with an anterior L5-S1 transvertebral cage. This technique is intended for both grade II spondylolisthesis and high sacral slope. The L5-S1 transvertebral cage may be sufficient to prevent further listhesis, fuse the patient, and alleviate axial back pain.