What is the initial treatment for cervical retrolisthesis?

Initial Treatment for Cervical Retrolisthesis

Conservative management with physical therapy, cervical immobilization, and pain control is the recommended initial treatment for cervical retrolisthesis, particularly when associated with radiculopathy, as this approach provides comparable long-term outcomes to surgical intervention while avoiding operative risks. 1

Conservative Treatment Protocol

First-Line Management (Minimum 6-12 Weeks)

• Physical therapy should be initiated as the cornerstone of conservative care, focusing on cervical stabilization exercises and postural correction 1, 2
• Cervical collar immobilization may be used for symptom relief during acute exacerbations, though prolonged use should be avoided to prevent muscle deconditioning 1
• Pain management with NSAIDs or acetaminophen as first-line pharmacotherapy for pain control 1
• Chiropractic manipulation with cervical traction may be considered in select cases, though this should be approached cautiously given the spinal instability 2, 3

Clinical Monitoring During Conservative Care

• Neurological assessment should be performed regularly to detect any progression of radiculopathy or development of myelopathy 1, 4
• Serial imaging is generally not required unless clinical deterioration occurs, as cervical retrolisthesis tends to remain stable over 2-8 years without progression 5
• Red flag symptoms requiring immediate surgical consultation include progressive motor weakness, bowel/bladder dysfunction, or signs of cervical myelopathy 1

Evidence Supporting Conservative Management

The strongest evidence comes from Class I data showing that anterior cervical decompression provides more rapid relief (within 3-4 months) compared to physical therapy or cervical immobilization for cervical radiculopathy 1. However, at 12 months, comparable clinical improvements are achieved with conservative therapy, making initial non-operative management appropriate for most patients 1.

Natural History Considerations

• Cervical retrolisthesis demonstrates stable behavior over 2-8 years in most patients, with no progression of subluxation or neurological deterioration 5
• Retrolisthesis patients may have slightly higher propensity for increased dynamic translation compared to anterolisthesis, but this rarely results in clinical worsening 5, 4
• Severe cord compression on MRI correlates with the level of spondylolisthesis and may predict need for surgical intervention 4

Indications for Surgical Consideration

Surgery should be considered when conservative management fails after 3-4 months or in the presence of specific clinical scenarios 1:

• Persistent or progressive radicular symptoms despite adequate conservative trial 1
• Progressive motor weakness or neurological deficit 1
• Development of cervical myelopathy with cord compression 1
• Severe dynamic instability with translation >2mm on flexion-extension radiographs causing symptoms 5

Surgical Options When Indicated

• Anterior cervical discectomy with or without fusion (ACDF) is recommended for rapid relief of radicular symptoms and provides longer-term improvement in specific motor functions 1
• Posterior approaches (laminectomy or laminoplasty) may be considered for multilevel disease or when anterior compression is minimal, though these carry risk of postoperative kyphosis 1

Common Pitfalls to Avoid

• Do not rush to surgery based solely on imaging findings—cervical retrolisthesis is relatively common (3.9% prevalence) and often asymptomatic 5
• Avoid prolonged cervical collar use beyond acute symptom management, as this can lead to muscle atrophy and deconditioning 1
• Do not overlook dynamic instability—obtain flexion-extension radiographs if clinical suspicion exists, as static films may miss significant translation 5, 6
• Distinguish between radiculopathy and myelopathy—the latter requires more urgent surgical evaluation and different treatment algorithms 1