Initial Treatment for Spondylolisthesis
Conservative management is the first-line treatment for spondylolisthesis and should include formal physical therapy for at least 6 weeks, NSAIDs, activity modification, and potentially epidural steroid injections before considering surgical intervention. 1, 2
Conservative Treatment Protocol
Duration and Components
- A minimum of 3-6 months of comprehensive conservative therapy is required before surgical intervention can be considered medically appropriate 1, 3, 4
- Formal physical therapy (not just home exercises) is essential and must be documented for at least 6 weeks 1, 2
- NSAIDs serve as first-line pharmacologic management for pain and inflammation 4, 5
- Activity modification to avoid positions that increase anterior vertebral displacement 6, 4
Specific Physical Therapy Approach
- Flexion-based exercises are superior to extension exercises for symptomatic spondylolisthesis, with only 19% of patients in flexion programs reporting moderate-to-severe pain at 3 years versus 67% in extension programs 6
- Abdominal strengthening through curl-ups and posterior pelvic tilts 6
- Hamstring and hip flexor stretching exercises 7
- Avoidance of maximal forward flexion of the lumbar spine 6
Additional Conservative Modalities
- Epidural steroid injections may provide short-term relief (typically less than 2 weeks) for radicular symptoms, though evidence is limited for isolated low back pain 1
- Transforaminal injections can be both diagnostic and therapeutic 1, 5
- Neuropathic pain medications (gabapentin, pregabalin) should be trialed for radicular symptoms 1
- Bracing with thoracolumbosacral orthosis may be beneficial, particularly in pediatric populations, though evidence in adults is mixed 6, 7
When Surgery Becomes Appropriate
Clear Indications for Surgical Consideration
- Failure of comprehensive conservative management for 3-6 months with persistent disabling symptoms 1, 2, 3
- Progressive neurological deficits or severe neurologic symptoms 2, 4
- Documented instability on flexion-extension radiographs combined with symptomatic stenosis 1, 2
- Cauda equina syndrome (requires prompt surgical intervention) 2
Surgical Approach Based on Pathology
- Decompression with fusion is strongly recommended for stenosis associated with degenerative spondylolisthesis, with 96% reporting excellent/good results versus 44% with decompression alone 8, 1, 2
- Decompression alone may be sufficient for stenosis without spondylolisthesis or instability 8, 2
- Pedicle screw fixation should be added when kyphosis or excessive motion is present on dynamic imaging 8, 1
Critical Pitfalls to Avoid
- Do not proceed to surgery without documented completion of formal physical therapy for at least 6 weeks, as this represents inadequate conservative management 1
- Avoid extension-based exercise programs, as they are associated with worse long-term outcomes compared to flexion programs 6
- Do not perform extensive decompression without fusion in patients with documented instability, as this significantly increases risk of iatrogenic instability 8, 9
- Recognize that epidural steroid injections provide only temporary relief and should not be considered definitive conservative treatment 1
Grade-Specific Considerations
- Grade I-II spondylolisthesis typically responds well to conservative management, with most patients achieving symptom relief 6, 4, 7
- Higher-grade slips or those with progressive neurological symptoms require closer monitoring and earlier surgical consideration 4, 7
- In pediatric populations, conservative treatment with bracing is highly effective, with excellent outcomes in 80% of cases 7