Initial Treatment for Retrolisthesis
Conservative management with supervised exercise programs focusing on flexion-based strengthening and core stabilization should be the initial treatment for retrolisthesis, maintained for at least 3-6 months before considering surgical intervention. 1, 2
First-Line Conservative Therapy
The initial approach prioritizes non-operative management unless red flags are present:
Structured physical therapy should emphasize flexion-based exercises (abdominal curl-ups, posterior pelvic tilts) rather than extension exercises, as flexion programs demonstrate superior outcomes with only 19% experiencing moderate-severe pain at 3-year follow-up versus 67% with extension programs 3
Core strengthening targeting paraspinal and abdominal muscles provides better spinal support and stability 1
Pain management includes non-narcotic analgesics, NSAIDs, and potentially neuropathic pain medications (gabapentin, pregabalin) for radicular symptoms 2, 4
Activity modification with instruction in proper body mechanics, posture, and lifting techniques should be implemented early 5, 3
Duration of conservative trial must be at least 6 weeks to 3-6 months before imaging or surgical consideration is warranted 6, 1, 2
Adjunctive Conservative Interventions
Epidural steroid injections may provide short-term relief for patients with radiculopathy, though evidence shows limited benefit for chronic low back pain without nerve root involvement 2, 4
Chiropractic manipulation with axial distraction and isometric stretching has demonstrated effectiveness in select cases, with one study showing gradual reduction in cervical retrolisthesis over 13 years of maintenance care 7
Antilordotic orthoses may be considered in younger patients (particularly adolescents) with grade I-II slippage, though evidence for adult use is mixed 5
When to Image
Imaging is not indicated initially unless red flags are present. Consider MRI lumbar spine only after:
Failure of 6 weeks of optimal conservative therapy in patients who are surgical candidates 6
Persistent or progressive neurological symptoms during conservative management 6, 1
Diagnostic uncertainty regarding the pain generator 6
Critical Pitfalls to Avoid
Do not order imaging prematurely - many MRI abnormalities exist in asymptomatic individuals, and early imaging often provides no benefit and may lead to unnecessary interventions 6
Avoid extension-based exercise programs - these show significantly worse outcomes (67% moderate-severe pain) compared to flexion programs (19% moderate-severe pain) at long-term follow-up 3
Do not rush to surgery - the overall recovery rate with flexion-based conservative therapy reaches 62% at 3 years, supporting an adequate trial of non-operative management 3
Surgical Consideration Criteria
Surgery should only be considered after conservative failure when:
3-6 months of comprehensive conservative management has been completed without adequate relief 1, 2, 8
Significant neurological symptoms or progressive instability are documented 1
Imaging correlates with clinical symptoms and demonstrates actionable pathology 6
Patient is a surgical candidate with realistic expectations and functional impairment justifying intervention 6, 2
For patients with retrolisthesis and spinal stenosis without significant instability, decompression alone may suffice; however, those with documented instability on flexion-extension films require decompression with fusion 1, 2