What is the initial treatment for a patient diagnosed with C4-C5 retrolisthesis?

Initial Treatment for C4-C5 Retrolisthesis

Conservative management with multimodal therapy is the appropriate initial treatment for C4-C5 retrolisthesis, including cervical manipulation, axial distraction, isometric stretching, and physical therapy for at least 6 weeks before considering any surgical intervention. 1

Conservative Treatment Protocol

The first-line approach should include:

• Cervical manipulation applied to the affected C4-C5 segments to address vertebral dysfunction and restore proper alignment 1
• Axial distraction therapy to decompress the neural structures and reduce pressure on the spinal cord or nerve roots 1
• Isometric stretching and cervical strengthening exercises to stabilize the affected segments and prevent progression 1
• Physical therapy for a minimum of 6 weeks as this represents the standard conservative trial period before imaging or surgical consideration 2, 3

When to Obtain Advanced Imaging

Initial plain radiographs are sufficient for diagnosis, but MRI becomes indicated if:

• Radiculopathy develops (pain radiating into the arm with sensory deficits in specific dermatomes) 1, 4
• Myelopathy signs appear (progressive weakness, gait disturbance, bowel/bladder dysfunction) 4
• Symptoms persist or progress despite 6 weeks of optimal conservative management 2, 3
• Instability is suspected on flexion-extension radiographs 4, 5

MRI has excellent soft-tissue contrast and accurately depicts cervical pathology including disc degeneration and neural compression 2. Flexion-extension radiographs are essential to identify segmental motion and instability 3, 5.

Red Flags Requiring Immediate Evaluation

Certain presentations warrant urgent assessment rather than conservative trial:

• Progressive myelopathy with upper motor neuron signs (hyperreflexia, positive Babinski, spasticity) 4
• Severe or rapidly progressive neurological deficits 3
• Suspected spinal cord compression on clinical examination 4

In these cases, immediate MRI and neurosurgical consultation are necessary rather than a trial of conservative care 4.

Maintenance Care Considerations

For patients who respond to initial conservative treatment:

• Monthly maintenance chiropractic care can be effective in preventing relapse and maintaining optimal spine function 1
• Disease monitoring with periodic imaging may show gradual reduction in retrolisthesis over time with consistent conservative management 1
• Ergonomics coaching and home exercise programs help maintain long-term stability 1

Surgical Indications

Surgery becomes appropriate only after conservative failure and includes:

• Persistent or progressive symptoms following 6 weeks of optimal medical management in surgical candidates 2, 3
• Documented instability on flexion-extension radiographs with neurological symptoms 4, 5
• Severe myelopathy or radiculomyelopathy that fails to improve with conservative care 4

Surgical approaches for cervical retrolisthesis include anterior discectomy and fusion, posterior fusion, or combined approaches depending on the degree of deformity, spinal cord compression location, and whether reduction is possible with positioning 4, 5. All eight patients in one series achieved satisfactory results with localized fusion (three anterior, five posterior) at 1-7 years follow-up 5.

Critical Pitfalls to Avoid

• Do not rush to surgery without an adequate 6-week conservative trial unless red flags are present 2, 3
• Do not obtain MRI immediately in the absence of radiculopathy, myelopathy, or red flags, as many imaging abnormalities are seen in asymptomatic individuals 2
• Do not ignore progressive neurological symptoms - these require urgent evaluation regardless of symptom duration 3, 4
• Do not assume neck pain alone requires surgery - in degenerative cervical spondylolisthesis, neck pain often decreases when neurological symptoms become more evident, and pain relief occurs in all patients treated surgically who complained of pain preoperatively 4