From the Guidelines
Treatment for spondylolisthesis should initially focus on conservative approaches, including pain management with nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy, before considering surgical options. According to the American College of Radiology's 2021 update on low back pain, initial imaging is not recommended in the absence of red flags, and first-line treatment remains conservative therapy with both pharmacologic and nonpharmacologic approaches 1.
Conservative Management
Conservative management includes:
- Pain management with NSAIDs like ibuprofen (400-800mg three times daily) or naproxen (250-500mg twice daily) for 1-2 weeks
- Physical therapy emphasizing core strengthening exercises, flexibility training, and proper body mechanics to stabilize the spine
- Activity modification to avoid movements that worsen symptoms, such as heavy lifting or excessive bending
- Epidural steroid injections for temporary relief in cases of persistent pain
- Short-term use of a back brace to limit movement and reduce pain
Surgical Intervention
Surgical options, such as spinal fusion or decompression, should be considered when conservative treatments fail, neurological symptoms develop, or the slippage is severe 1. Imaging modalities like MRI, CT myelography, and upright radiographs, including flexion and extension radiographs, are essential in assessing the need for surgical intervention and planning 1.
Imaging Modalities
Imaging modalities play a crucial role in the diagnosis and treatment planning of spondylolisthesis.
- MRI is the initial imaging modality of choice, providing excellent soft-tissue contrast and accurately depicting lumbar pathology
- CT myelography can be useful in assessing the patency of the spinal canal/thecal sac and of the subarticular recesses and neural foramen
- Upright radiographs, including flexion and extension radiographs, provide useful functional information about axial loading and segmental motion.
From the Research
Treatment Options for Spondylolisthesis
The treatment for spondylolisthesis can be categorized into non-surgical and surgical management.
- Non-surgical management is the first-line approach for low-grade spondylolisthesis (Grade I-II) and includes:
- Physical therapy
- Activity modification
- Pain management with nonsteroidal anti-inflammatory drugs or epidural steroid injections
- Bracing, in some cases
- Surgical options are typically considered for patients with progressive neurological deficits, severe pain, or significant instability, and may include:
- Decompression for nerve compression
- Fusion to stabilize the spine
- Posterior lumbar interbody fusion and transforaminal lumbar interbody fusion are common techniques
- Minimally invasive surgery is gaining popularity due to its less aggressive impact on tissues and faster recovery 2
Classification and Treatment Approach
Spondylolisthesis can be classified into different types, with isthmic and degenerative being the most prevalent.
- Isthmic spondylolisthesis is often seen with a defect in the pars interarticularis of L5, resulting in slippage of L5 on S1
- Degenerative spondylolisthesis arises from the remodeling of the facet joints, commonly occurring at the L4-5 level in women over 40
- The treatment approach may vary depending on the type and severity of the condition, as well as the presence of neurological deficits 3, 4
Conservative Management
Conservative management is a crucial aspect of treating spondylolisthesis, especially for patients with symptomatic grade I or II isthmic or degenerative spondylolisthesis.
- Documented conservative treatment includes:
- Instruction in exercise and body mechanics
- Use of back supports, such as antilordotic orthoses
- Job modifications
- Strengthening of the abdominals and paraspinal muscles
- Deep-heat therapy and avoidance of maximal forward flexion of the lumbar spine
- A minimal trial period of three to four months is recommended for conservative treatment 4
Surgical Intervention
Surgical intervention may be necessary for patients who fail conservative management or have significant instability.
- The use of instrumentation for posterolateral fusions and interbody fusion may improve clinical outcomes
- Decompression alone or decompression with fusion are surgical options, although the choice between them remains controversial, particularly in degenerative spondylolisthesis without initial instability 2, 5
- Long-term follow-up is necessary to monitor for complications such as adjacent segment disease, pseudarthrosis, or reoperation rate 2