From the Guidelines
The recommended treatment for a patient with spondylolysis at L5-S1 with grade 1 anterolisthesis and disc space narrowing typically begins with conservative management. This approach is supported by the American College of Radiology's 2021 update on low back pain, which emphasizes the importance of conservative therapy, including pharmacologic and nonpharmacologic treatments, as the first-line treatment for chronic low back pain 1.
Initial Treatment
Initial treatment should include a combination of:
- Relative rest
- Activity modification
- Physical therapy focusing on core strengthening and lumbar stabilization exercises for 6-12 weeks Pain management can be achieved with:
- NSAIDs such as ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) for 2-3 weeks
- Muscle relaxants like cyclobenzaprine (5-10mg at bedtime) for muscle spasms if present
Physical Therapy
Physical therapy should emphasize:
- Extension-based exercises
- Core strengthening
- Hamstring stretching
- Sessions 2-3 times weekly for 6-8 weeks
Additional Support
A lumbosacral orthosis brace may provide temporary relief during acute pain phases but should be limited to 4-6 weeks to prevent muscle deconditioning.
Next Steps
If conservative measures fail after 3-6 months, epidural steroid injections may be considered. Surgery (typically decompression with or without fusion) is reserved for cases with persistent pain, neurological deficits, or progression of the slippage beyond grade 1. This stepped approach is recommended because most patients with grade 1 slippage respond well to conservative treatment, and the condition often stabilizes without surgical intervention 1.
Imaging and Further Evaluation
Imaging modalities such as MRI, CT myelography, and CT lumbar spine without IV contrast may be useful in assessing the extent of the condition and guiding further treatment, including surgical options if necessary 1. However, the primary focus should remain on conservative management unless clear indications for more invasive procedures are present.
From the Research
Treatment Options for Spondylolysis at L5-S1 with Grade 1 Anterolisthesis
- The recommended treatment for a patient with spondylolysis at L5-S1 with grade 1 anterolisthesis and disc space narrowing typically involves conservative management, including instruction in exercise and body mechanics, the use of back supports, and job modifications 2.
- Conservative treatment may also include strengthening of the abdominals and paraspinal muscles, occupational modifications, instruction in body mechanics, deep-heat therapy, avoidance of maximal forward flexion of the lumbar spine, and in severe cases, bed rest 2.
- A study by Gramse et al. and Sinaki et al. found that patients treated with a flexion exercise program were less likely to require the use of back supports, require job modification, or limit their activities because of pain 2.
- 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, and, in some cases, bracing 3.
- Surgical intervention may be necessary for patients with progressive neurological deficits, severe pain, or significant instability 3.
Surgical Options
- Surgical options typically include decompression for nerve compression and fusion to stabilize the spine 3.
- Posterior lumbar interbody fusion and transforaminal lumbar interbody fusion are the most performed techniques, with minimally invasive surgery gaining popularity due to its less aggressive impact on tissues and faster recovery 3.
- A systematic review by 4 found that pars repair is a viable option for adults with spondylolysis or grade-I spondylolisthesis, with successful outcomes reported in 86% of patients treated with Buck's repair and ≥90% treated with Scott's, Morscher's, and pedicle-screw-based techniques.
Case Reports and Literature Review
- A case report by 5 described a patient with traumatic anterolisthesis at multiple levels (L3,4,5 over S1) due to pedicle avulsion, who underwent decompression and pedicle screw fixation with satisfactory neurological recovery.
- A review of literature by 6 presented two cases of traumatic spondylolisthesis at L5-S1, one with anterior dissociation and the other with posterior dissociation, both treated with open reduction internal fixation and posterior spinal fusion.