Management of Multilevel Spondylolisthesis: Grade I Retrolisthesis at L2-3 and L3-4, Grade II Anterolisthesis at L4-5
Conservative management should be the first-line treatment for patients with multilevel spondylolisthesis, including structured physical therapy, pain management, and activity modification, with surgical intervention reserved for cases with persistent severe symptoms or neurological deficits despite 6 weeks of comprehensive conservative treatment.
Initial Assessment and Conservative Management
Physical Therapy and Exercise
- Begin with a structured physical therapy program focused on:
- Core strengthening exercises, particularly abdominal strengthening 1
- Flexion-based exercises (posterior pelvic tilts, seated trunk flexion) which have shown better outcomes than extension exercises for spondylolisthesis 1
- Weight-bearing exercises to maintain joint range and maximize strength and endurance 2
Pain Management
- Non-opioid analgesics and anti-inflammatory medications
- Consider targeted nerve blocks for specific levels:
- L2 nerve root blocks may be beneficial for pain from L3-4 retrolisthesis 2
Bracing and Support
- Consider an antilordotic orthosis/brace for temporary support during acute pain phases 1
- Note that while bracing has shown 100% success in some pediatric studies, results are less consistent in adults 1
Activity Modification
- Avoid activities that exacerbate pain, particularly those involving maximal forward flexion of the lumbar spine 1
- Implement ergonomic modifications at work and home
- Maintain appropriate body mechanics during daily activities
Monitoring and Follow-up
Imaging Follow-up
- Standing lumbosacral X-rays are recommended as the initial diagnostic imaging study 3
- Follow-up imaging at 12 months post-treatment, or earlier if symptoms worsen 2
- MRI without contrast is suggested for persistent radicular symptoms after 6 weeks of failed conservative management 3
Duration of Conservative Management
- A minimum trial of comprehensive conservative management for at least 6 weeks is recommended before considering surgical intervention 3
- Some experts recommend 3-4 months as the minimal trial period for conservative treatment 1
Indications for Surgical Intervention
Absolute Indications
- Motor deficit greater than grade 3/5
- Cauda equina syndrome
- Progressive neurological deficits 3
Relative Indications
- Persistent severe radicular pain despite 6 weeks of comprehensive conservative management
- Mechanical instability with persistent symptoms
- Spinal deformity causing pulmonary dysfunction 2
- Persisting deformity with mechanical axis deviation Zone 2 or greater despite optimized medical treatment 2
Surgical Considerations
Timing of Surgery
- Surgical treatment should be performed only after conservative management has been maximized for at least 12 months 2
- Emergency surgical treatment such as fracture fixation should occur when necessary 2
Surgical Approach
- Surgery should be performed by a surgeon with expertise in metabolic bone diseases 2
- Decompressive surgery has demonstrated effectiveness for lumbar stenosis with radiculopathy, with response rates exceeding 80-90% for appropriate candidates 3
- Surgical options include:
- Posterior approach with laminectomy
- Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF)
- Anterior approach for lumbar spinal fusion 3
Post-Surgical Management
- Regular clinical and functional assessments should be made following surgery
- Radiographic assessment at 12 months post-surgery, or earlier if bone deformity worsens 2
- Continue physical therapy post-surgery to maintain range of motion and strength 2
Special Considerations
Multilevel Involvement
- Multilevel spondylolisthesis patterns are less common and may have different biomechanical considerations than single-level disease 4
- Anterolisthesis is associated with increased pedicle-facet angle and W-shaped facet joints, while retrolisthesis has different pathomechanical factors 4
Stability Assessment
- Assess for signs of instability that may influence treatment decisions
- Note that retrolisthesis may be relatively stable if the posterior ligamentous complex remains intact 5
Prognosis
- Approximately 80% of patients with lumbar spine conditions experience symptom resolution with appropriate conservative treatment 3
- Patients with retrolisthesis and disc herniation may have somewhat worse postoperative outcomes compared to those without retrolisthesis 6
- Long-term maintenance care may help maintain an asymptomatic status and potentially reduce retrolisthesis over time 7