From the Guidelines
Management for grade one retrolisthesis of L3 on L4 should initially focus on conservative therapy, including pharmacologic and nonpharmacologic treatments, as outlined in the American College of Radiology's 2021 update on low back pain 1. The initial approach to managing grade one retrolisthesis involves a combination of physical therapy, pain management, and activity modification. Key components of physical therapy include:
- Core strengthening exercises
- Lumbar stabilization
- Proper body mechanics to support the affected vertebral segment Pain management may involve the use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen for a short duration, typically 1-2 weeks, along with muscle relaxants for muscle spasms. It is essential to modify activities to avoid exacerbating symptoms, including avoiding heavy lifting and prolonged sitting. Heat therapy can be beneficial for relieving muscle tension, and some patients may benefit from a short course of spinal manipulation by a qualified practitioner. According to the American College of Radiology's guidelines, imaging such as MRI of the lumbar spine may be considered if conservative therapy fails after 6 weeks, especially if there are signs of radiculopathy or spinal stenosis, as it can help identify potential actionable pain generators 1. Surgical intervention is typically reserved for cases with neurological deficits or when conservative management fails completely, highlighting the importance of a stepwise approach that prioritizes conservative management initially.
From the Research
Management of Grade One Retrolisthesis of L3 on L4
The management of grade one retrolisthesis of L3 on L4 can be approached through various methods, including conservative management and surgical intervention.
- Conservative Management: This approach includes physical therapy, bracing, and restriction of offending activities. A study by 2 found that conservative management techniques, such as physical therapy and restriction of activities, can be effective in relieving pain and restoring function in patients with symptomatic spondylolysis and grade I spondylolisthesis.
- Chiropractic Care: Chiropractic maintenance care has been shown to be effective in reducing retrolisthesis and alleviating symptoms. A case study by 3 demonstrated the effectiveness of long-term monthly chiropractic maintenance care in reducing cervical retrolisthesis and alleviating associated symptoms.
- Surgical Intervention: In some cases, surgical intervention may be necessary to address retrolisthesis, particularly if it is associated with significant spinal instability or neurological symptoms. However, the decision to undergo surgery should be made on a case-by-case basis, taking into account the individual patient's condition and medical history.
Risk Factors and Clinical Features
Retrolisthesis has been associated with various risk factors, including increased age, female gender, and degenerative spinal conditions. A study by 4 found that retrolisthesis occurs frequently at the L3/4 level and is associated with a larger thoracolumbar junctional angle. Another study by 5 found that retrolisthesis acts as a compensatory mechanism for sagittal imbalance in the lumbar spine, particularly in patients with low pelvic incidence and insufficient intra-spinal compensation.
Preoperative Assessment
In patients with lumbar disc herniation, retrolisthesis has been associated with increased back pain and impaired back function. A study by 6 found that the presence of retrolisthesis was not associated with an increased incidence of degenerative disc disease, posterior degenerative changes, or vertebral endplate changes, and did not affect preoperative low back pain and physical function. However, the study suggested that retrolisthesis may be associated with worse outcomes after discectomy, although further research is needed to confirm this finding.