What are the treatment options and referrals for a patient with mild grade 1 anterior listhesis of C3 and moderate degenerative changes with loss of disc height at C5-C6?

Management of Cervical Spondylolisthesis with Degenerative Changes

For a patient with mild grade 1 anterior listhesis of C3 and moderate degenerative changes with loss of disc height at C5-C6, conservative management should be the initial approach, including physical therapy, pain management, and cervical strengthening exercises, before considering surgical referral if symptoms persist or worsen.

Initial Assessment and Imaging

• Evaluate for neurological symptoms:

  • Radiculopathy (radiating pain, numbness, tingling in arms)
  • Myelopathy (gait disturbance, hand clumsiness, hyperreflexia)
  • Motor or sensory deficits in upper extremities
  • Bladder/bowel dysfunction (rare but concerning)

• Additional imaging considerations:

  • MRI of cervical spine if neurological symptoms are present
  • Flexion-extension X-rays to assess for dynamic instability
  • Consider CT for better bony detail if surgical planning is needed

Conservative Management Approach

1. Pain Management:

   • Short-term NSAIDs for pain and inflammation
   • Acetaminophen as an alternative if NSAIDs are contraindicated
   • Short-term muscle relaxants if significant muscle spasm is present
   • Consider gabapentin or pregabalin for neuropathic pain if radicular symptoms are present 1

2. Physical Therapy:

   • Cervical strengthening exercises focusing on deep neck flexors and extensors
   • Isometric stretching to improve range of motion
   • Postural education and ergonomic modifications
   • Axial distraction techniques 2

3. Activity Modification:

   • Avoid activities that exacerbate symptoms
   • Proper ergonomics at work and home
   • Cervical support during sleep if needed

4. Other Conservative Measures:

   • Soft cervical collar for short-term use during acute pain flares (limit to 1-2 weeks)
   • Consider epidural steroid injections for persistent radicular symptoms after 6 weeks of conservative care 1

Monitoring and Follow-up

• Re-evaluate after 6 weeks of conservative management
• Monitor for progression of neurological symptoms
• Consider repeat imaging if symptoms worsen or change in character
• Long-term monitoring may be beneficial, as shown in a case report where monthly chiropractic maintenance care over 13 years resulted in reduction of cervical retrolisthesis 2

Indications for Surgical Referral

Refer to a neurosurgeon or orthopedic spine surgeon if:

1. Progressive neurological deficits develop
2. Severe or incapacitating pain unresponsive to 6-12 weeks of conservative management
3. Evidence of spinal cord compression on imaging
4. Documented spinal instability (>3.5mm of translation on flexion-extension views)
5. Development of myelopathic symptoms 1

Prognosis

• Prognosis is generally favorable with conservative management for mild cases
• Patients with neurological symptoms may experience deterioration if not appropriately managed 3
• Degenerative changes at one level can affect the mechanics of adjacent segments, potentially leading to adjacent segment disease 4
• Anterolisthesis tends to have greater impact on the development of cervical spondylotic myelopathy than retrolisthesis with similar degree of displacement 5

Important Considerations

• Avoid premature surgical intervention before adequate trial of conservative management
• Document all attempted conservative measures thoroughly
• Recognize that approximately 80% of patients with degenerative spine conditions experience symptom improvement with appropriate conservative treatment 1
• Patients with documented neural compression symptoms who fail conservative management for at least 6 weeks are candidates for surgical intervention 1