What is the recommended treatment for a patient with anterolisthesis of C2 on C3, retrolisthesis of C3 on C4, anterolisthesis of C4 on C5, and retrolisthesis of C5 on C6 with mild canal narrowing at C5/C6?

Treatment for Cervical Spondylosis with Multiple Listhesis and Mild Canal Narrowing

For patients with multiple cervical listhesis (anterolisthesis of C2 on C3, retrolisthesis of C3 on C4, anterolisthesis of C4 on C5, retrolisthesis of C5 on C6) and mild canal narrowing at C5/C6, conservative management should be the first-line treatment, with surgical intervention reserved for progressive neurological deficits or intractable pain.

Initial Assessment and Conservative Management

• Evaluate for signs of myelopathy including gait abnormalities, hand dexterity issues, hyperreflexia, and sensory changes, as these findings would influence treatment decisions 1
• Conservative management should be the initial approach for patients without significant neurological deficits, consisting of:
  • Physical therapy focusing on cervical stabilization exercises 2
  • Non-steroidal anti-inflammatory medications for pain control 2
  • Activity modification to avoid positions that exacerbate symptoms 1
• Monitor for progression of symptoms, as alternating anterolisthesis and retrolisthesis patterns may lead to dynamic cord compression during movement 1

Indications for Surgical Intervention

• Progressive neurological deficits despite conservative management 2
• Intractable pain unresponsive to non-surgical treatments 2
• Evidence of significant cord compression on MRI with corresponding clinical symptoms 1
• Development of myelopathic signs (particularly important as anterolisthesis tends to have greater impact on CSM development than retrolisthesis) 1

Surgical Considerations

• For patients requiring surgery, posterior decompression with fusion is recommended to address the multiple levels of listhesis and prevent further instability 2
• Laminectomy with fusion is preferred over laminectomy alone to prevent late deformity in cervical spine 2
• The surgical approach should address all involved segments (C2-C6) to prevent adjacent segment disease 2
• Instrumented fusion provides better stability for patients with multiple level listhesis 2

Important Considerations in Surgical Decision-Making

• Timing of surgery remains controversial, with insufficient evidence to make definitive recommendations regarding early versus late intervention 2
• Recent evidence suggests caution with early surgical intervention in cases without significant canal compromise, as neurological deterioration can occur postoperatively 2
• The pattern of alternating anterolisthesis and retrolisthesis affects foraminal dimensions differently:
  • Anterolisthesis tends to increase foraminal area at the level above 3
  • Retrolisthesis decreases foraminal area at the level below by approximately 12% per millimeter of displacement 3

Monitoring and Follow-up

• Regular clinical and radiographic follow-up is essential to monitor for:
  • Progressive listhesis at involved or adjacent levels 4
  • Development of new neurological symptoms 1
  • Changes in cervical alignment that may indicate instability 1

Prognosis

• Patients with anterolisthesis tend to have a wider spinal canal than those with retrolisthesis, which may affect the development and progression of myelopathy 1
• The presence of multiple level listhesis is associated with greater cervical mobility, which may contribute to the development of cervical spondylotic myelopathy in elderly patients 1
• The combination of anterolisthesis and retrolisthesis at multiple levels increases the risk of dynamic cord compression during movement 1

Pitfalls and Caveats

• Avoid overlooking the significance of mild canal narrowing at C5/C6, as this is a common site for cervical spondylotic myelopathy 1
• Be cautious about attributing symptoms solely to radiographic findings, as the correlation between imaging and clinical presentation can be variable 5
• Consider that patients with multiple level listhesis may have compensatory changes in cervical mobility that affect their presentation and treatment response 1