What is the initial treatment for a patient with retrolisthesis?

Initial Treatment for Retrolisthesis

The initial treatment for retrolisthesis is conservative management with supervised exercise programs focusing on paraspinal and abdominal muscle strengthening, combined with remaining active, for a minimum of 6 weeks before considering any imaging or surgical intervention. 1, 2

Conservative Management Protocol

First-Line Treatment (Minimum 6 Weeks)

• Supervised exercise therapy targeting paraspinal and abdominal muscles to provide better spinal support is the cornerstone of initial management 2
• Flexion-based exercises (abdominal curl-ups, posterior pelvic tilts, seated trunk flexion) are superior to extension exercises, with only 19% experiencing moderate-to-severe pain at 3-year follow-up compared to 67% in extension exercise groups 3
• Remaining physically active rather than bed rest is recommended, avoiding prolonged immobilization 1
• Pharmacologic management includes non-narcotic pain medications and anti-inflammatory agents 4, 5

Additional Conservative Options (If Initial Therapy Insufficient)

• Neuroleptic medications (gabapentin or pregabalin) may be added for radicular symptoms 6
• Epidural steroid injections can provide short-term relief (less than 2 weeks duration) for radiculopathy, though evidence for isolated low back pain is limited 6, 4, 5
• Physical therapy should be formal and comprehensive, not just home exercises 6
• Body mechanics instruction and ergonomic modifications are important adjuncts 3

When to Image

Do not obtain imaging initially unless red flags are present. 1 Imaging is only indicated after:

• Failure of 6 weeks of optimal conservative management in patients who are surgical candidates 1
• Presence of red flags (progressive neurological deficits, cauda equina symptoms, trauma, infection concerns) 1
• Diagnostic uncertainty that would change management 1

Imaging Modality Selection

• MRI lumbar spine is the initial imaging modality of choice when indicated, providing excellent soft-tissue contrast and depicting disc degeneration, neural structures, and potential nerve root compression 1
• Upright radiographs with flexion-extension views are essential to identify segmental motion and instability, which is critical for surgical planning if conservative management fails 1

Duration of Conservative Trial

A minimum of 3-6 months of comprehensive conservative management is required before considering surgical intervention. 2, 6, 4, 5 This includes:

• Formal physical therapy (not just home exercises) 6
• Trial of appropriate medications 6
• Activity modification and ergonomic adjustments 3
• Consideration of injections if radicular symptoms present 4, 5

Critical Pitfalls to Avoid

• Premature imaging: Many MRI abnormalities are seen in asymptomatic individuals; imaging patients without adequate conservative trial and surgical candidacy is not beneficial 1
• Extension-based exercises: These are associated with worse outcomes compared to flexion-based programs in spondylolisthesis/retrolisthesis 3
• Inadequate conservative trial: Jumping to surgery without completing 3-6 months of comprehensive conservative management, including formal physical therapy, is inappropriate 2, 6
• Ignoring instability: If flexion-extension radiographs eventually show significant motion (>3-4mm translation), this changes management toward fusion rather than decompression alone 1, 2

When Conservative Management Fails

If symptoms persist or progress after 3-6 months of optimal conservative management:

• Without instability or spondylolisthesis: Decompression alone may be sufficient 1, 2
• With documented instability or associated spondylolisthesis: Decompression with fusion is recommended 1, 2, 6
• With progressive neurological deficits: More urgent surgical evaluation is warranted 2