What are the management options for spondylolisthesis (slippage of the spine) at L4-L5 with radiculopathy (nerve root damage)?

Management Options for Spondylolisthesis L4-L5 with Radiculopathy

Surgical decompression with fusion is the recommended treatment for symptomatic L4-L5 spondylolisthesis with radiculopathy after failure of conservative management. 1

Initial Conservative Management (First-Line)

Conservative management should be attempted for 6 weeks before considering surgical intervention:

• Physical therapy with flexion-based exercises (abdominal curl-ups, posterior pelvic tilts, seated trunk flexion) is superior to extension exercises for symptomatic spondylolisthesis 2
• Pain management with non-narcotic and narcotic medications as appropriate 3
• Epidural steroid injections or transforaminal injections for radicular symptoms 4
• Activity modification with avoidance of maximal forward flexion 2

Surgical Management (After Failed Conservative Treatment)

Surgical intervention should be considered when:

• Persistent or progressive symptoms after 6 weeks of optimal conservative management 1
• Significant neurological symptoms including radiculopathy 1
• Functional limitations affecting quality of life 1

Recommended Surgical Approach

• Decompression with fusion is superior to decompression alone for spondylolisthesis with radiculopathy 1
• Posterolateral fusion (PLF) following decompression is the standard approach 1
• Pedicle screw fixation should be considered in cases with:
  • Kyphosis at the level of spondylolisthesis 1
  • Evidence of instability on dynamic imaging 1

Diagnostic Imaging Prior to Intervention

• MRI is the initial imaging modality of choice for patients with radiculopathy who have failed conservative therapy 1
• Upright radiographs with flexion-extension views are essential to identify segmental motion and instability 1
• CT myelography can be useful when MRI is contraindicated or to better assess bony anatomy 1

Evidence Supporting Surgical Intervention

The SPORT studies provide the strongest evidence supporting surgical intervention for spondylolisthesis with stenosis, demonstrating:

• Superior outcomes in all clinical measures for at least 4 years following surgical treatment compared to non-operative management 1
• Higher satisfaction rates and improved functional outcomes with decompression and fusion 1

Potential Complications and Considerations

• Risk of iatrogenic instability if decompression is performed without fusion 5
• Potential for nerve root injury, dural tear, or infection 6
• Failure of fusion or hardware complications 1

Follow-up Care

• Regular radiographic assessment to evaluate fusion status 1
• Continued physical therapy focusing on core strengthening 2
• Monitoring for adjacent segment disease in long-term follow-up 1

The evidence strongly supports surgical decompression with fusion for symptomatic spondylolisthesis with radiculopathy that has failed conservative management, with multiple studies demonstrating superior outcomes compared to non-operative treatment or decompression alone.