Causes of Cervical Retrolisthesis
Cervical retrolisthesis results primarily from degenerative facet joint arthropathy, with disc degeneration and spinal instability as contributing factors. 1, 2, 3
Primary Degenerative Mechanisms
Facet joint degeneration is the universal finding in all cases of cervical retrolisthesis, representing the fundamental pathologic process that allows posterior vertebral displacement. 2, 4 The facet joints become "ground-down" with progressive narrowing of the joint space, and the articular facets themselves become thinned or ribbon-like in appearance. 4
Key Degenerative Contributors:
Intervertebral disc degeneration at the affected level creates biomechanical instability that permits retrolisthesis to develop, though disc changes alone are insufficient without facet pathology. 2, 3
Advanced spondylosis at adjacent levels creates a distinct pattern where retrolisthesis occurs at mobile segments adjacent to severely degenerated, relatively fixed segments—this represents a compensatory mechanism for lost motion. 2, 3
Increased segmental mobility in the upper cervical spine (C3-C5) develops as compensation for advanced disc degeneration in lower segments, predisposing these levels to retrolisthesis. 3 The C4-C5 level is most frequently involved (43% of cases). 2
Traumatic Causes
Traumatic retrolisthesis represents a distinct entity from degenerative retrolisthesis and can be differentiated radiographically by specific features. 4
Distinguishing Features of Traumatic Retrolisthesis:
Abnormally widened facet joint spaces rather than narrowed spaces seen in degenerative disease. 4
Fractured or normally-shaped articular facets rather than the thinned, ribbon-like facets of degenerative disease. 4
Acute onset following significant trauma such as falls from height, with associated disc extrusion and nerve root injury. 5
Secondary Contributing Factors
Congenital spinal canal dimensions influence the clinical impact of retrolisthesis, though they do not cause the displacement itself. 3 Patients with retrolisthesis and narrower baseline spinal canal dimensions develop more severe cord compression compared to those with anterolisthesis at similar degrees of displacement. 3
Biomechanical Considerations:
Cervical hypermobility at affected segments correlates with more severe degrees of retrolisthesis (≥3.5 mm displacement). 3
Multilevel involvement occurs in the majority of cases, with 72 levels of involvement identified across 58 patients in one surgical series. 2
Clinical Implications
The presence of retrolisthesis indicates underlying facet instability and carries high risk for neurologic compression. 1, 2 Severe cord compression on T1-weighted MRI and high-intensity spinal cord signals on T2-weighted MRI correspond significantly to the levels of retrolisthesis. 3
Red Flags Requiring Urgent Evaluation:
Progressive myelopathy with gait disturbance, weakness, or sensory changes indicates spinal cord compression requiring urgent imaging. 1, 6
Radiculopathy with dermatomal sensory deficits or motor weakness suggests nerve root compression at the retrolisthesis level. 7
Constitutional symptoms including fever, unexplained weight loss, or elevated inflammatory markers (ESR, CRP) raise concern for inflammatory or infectious causes of instability. 1, 6