What is the initial treatment for a patient with anterolisthesis?

Initial Treatment for Anterolisthesis

The initial treatment for anterolisthesis is conservative management for at least 6 weeks, including formal physical therapy with flexion-based exercises, non-narcotic pain medications, and remaining active, before considering any imaging or surgical intervention. 1, 2

Conservative Management Protocol

First-Line Treatment (6 weeks minimum)

• Formal physical therapy is mandatory as the cornerstone of conservative treatment, with flexion-based exercises showing superior outcomes over extension exercises (62% recovery rate vs 0% at 3-year follow-up) 3
• Non-narcotic pain medications and anti-inflammatory agents should be initiated 1, 4
• Patients should be instructed to remain active rather than bed rest 1
• Posture correction and proper lifting techniques must be taught 3

Additional Conservative Options (if symptoms persist after 6 weeks)

• Neuroleptic medications (gabapentin or pregabalin) for radicular symptoms 2
• Epidural steroid injections for short-term relief, though evidence shows duration of relief less than 2 weeks for chronic low back pain without radiculopathy 2, 4
• Transforaminal injections may be considered 5
• Facet joint injections can be both diagnostic and therapeutic, as facet-mediated pain causes 9-42% of chronic low back pain 2

When Imaging is Indicated

Do not obtain imaging initially unless red flags are present. 1 Imaging should only be pursued after 6 weeks of failed conservative therapy if the patient is a surgical candidate or diagnostic uncertainty remains 1

• MRI lumbar spine is the initial imaging modality of choice, with excellent soft-tissue contrast for depicting disc degeneration and neural structures 1
• Upright radiographs with flexion-extension views are essential to identify segmental motion and instability, which is critical for surgical planning in spondylolisthesis 1

Critical Pitfalls to Avoid

• Premature imaging: Many MRI abnormalities are seen in asymptomatic individuals; imaging patients without adequate conservative trial is often not beneficial 1
• Extension exercises: Avoid extension-based strengthening programs, as they show significantly worse outcomes (67% with moderate-severe pain at 3 years) compared to flexion exercises (19% with moderate-severe pain) 3
• Incomplete physical therapy: Lack of formal, structured physical therapy is a critical deficiency that undermines the conservative treatment algorithm 2

Surgical Consideration Criteria

Surgery should only be considered after comprehensive conservative management failure for 3-6 months and when the following are present: 2

• Documented instability or spondylolisthesis on flexion-extension films
• Persistent disabling symptoms despite optimal medical management
• Significant functional impairment
• Pain that correlates with imaging findings

Decompression with fusion is superior to decompression alone for symptomatic spondylolisthesis (96% excellent/good results vs 44%), with statistically significant reductions in back pain (p=0.01) and leg pain (p=0.002) 2, 6