Systemic Corticosteroids Are Not Recommended for Chronic Symptomatic High-Grade Spondylolisthesis
Prednisone or methylprednisolone dose packs should not be used for chronic symptomatic high-grade spondylolisthesis, as systemic corticosteroids lack evidence for axial spinal disease and are strongly recommended against in spondyloarthropathies. 1
Evidence Against Systemic Corticosteroids for Axial Disease
The American College of Rheumatology/Spondylitis Association of America guidelines explicitly strongly recommend against treatment with systemic glucocorticoids for axial spondyloarthropathies, based on very low-quality evidence showing minimal benefit. 1 While these guidelines address ankylosing spondylitis specifically, the principle applies to other axial spine conditions including spondylolisthesis.
- A randomized placebo-controlled trial of high-dose prednisolone (50 mg daily) showed only 5 of 10 outcomes favoring treatment over placebo in a 2-week period. 1
- Case series examining systemic glucocorticoids over 4-6 months showed only modest improvements with serious risk of bias and imprecise effect estimates. 1
- The use of systemic corticosteroids for axial disease is not supported by evidence. 1
Appropriate Conservative Management for Spondylolisthesis
For chronic symptomatic high-grade spondylolisthesis, evidence-based conservative management includes:
First-Line Treatment
- Physical therapy with core strengthening, hamstring stretching, and spine range-of-motion exercises is the cornerstone of conservative management. 2
- NSAIDs for pain control should be considered as the primary pharmacologic intervention. 3, 4
- Activity modification and restriction of offending activities. 2
Second-Line Interventions
- Transforaminal epidural steroid injections (TFE) may provide pain relief, though effectiveness varies by spondylolisthesis type. 5
- Degenerative spondylolisthesis responds better to TFE than isthmic spondylolisthesis (72% vs 54% pain relief). 5
- However, epidural steroid injections show little effect on long-term clinical outcomes and do not reduce surgical crossover rates over 4 years. 6
Limited Role for Short-Term Systemic Corticosteroids
The only circumstances where short-term systemic glucocorticoids might be considered (with rapid tapering) are extremely limited and do not include chronic axial disease:
- Polyarticular flare of peripheral arthritis 1
- Flares during pregnancy 1
- Concomitant flares of inflammatory bowel disease 1
None of these scenarios apply to chronic symptomatic high-grade spondylolisthesis.
Clinical Outcomes with Conservative Management
A cross-sectional study of patients with symptomatic spondylolysis and grade I spondylolisthesis treated with physical therapy and activity modification (without bracing) demonstrated:
- 96% achieved minimal disability scores (0-19.9% on Oswestry Disability Questionnaire). 2
- 78% had disability scores of zero, indicating no pain or functional limitation. 2
- Pain relief and functional restoration were achieved without systemic corticosteroids. 2
Surgical Considerations
For patients with progressive neurological deficits, severe refractory pain, or significant instability despite conservative management, surgical intervention (decompression with or without fusion) becomes appropriate. 3, 4 Systemic corticosteroids do not alter this treatment algorithm or delay the need for surgery when indicated.