What is the recommended treatment for a patient with straightening of the cervical spine, mild anterolisthesis (forward displacement) of C2 on C3, mild retrolisthesis (backward displacement) of C5 on C6, and multilevel degenerative disc disease?

Management of Cervical Spine Straightening with Mild Listhesis and Multilevel Degenerative Disc Disease

Conservative management with structured physical therapy for at least 3-6 months is the recommended initial approach for this imaging pattern, as these findings are common in asymptomatic individuals and do not automatically warrant surgical intervention. 1, 2

Clinical Context and Natural History

The imaging findings described—straightening of cervical lordosis, mild anterolisthesis at C2-C3, mild retrolisthesis at C5-C6, and multilevel degenerative disc disease—represent common age-related changes that frequently occur without clinical significance. Cervical degenerative anterolisthesis and retrolisthesis demonstrate stable natural history over 2-8 years of follow-up, with no progression of subluxation or neurological deterioration in the vast majority of cases. 3

• Cervical retrolisthesis shows higher propensity for increased subluxation over time compared to anterolisthesis, but neither condition leads to dislocation or neurological injury during medium-term follow-up 3
• The absence of central canal narrowing is a favorable prognostic indicator, as cord compression is the primary determinant of surgical necessity 4
• Normal prevertebral soft tissues exclude acute traumatic injury or infection 5

Initial Conservative Management Algorithm

Begin with a comprehensive rehabilitation program for 3-6 months before considering any advanced interventions or imaging. 1, 2

Structured Physical Therapy (6-12 weeks minimum)

• Core strengthening exercises targeting cervical paraspinal musculature 1
• Flexibility training to maintain cervical range of motion 1
• Postural correction techniques, particularly for loss of cervical lordosis 2
• Pain management modalities including heat, ice, and manual therapy 1

Pharmacological Management

• Trial of neuropathic pain medications (gabapentin or pregabalin) if radicular symptoms develop 6, 2
• Anti-inflammatory medications for axial neck pain 6
• Avoid long-term opioid therapy given poor outcomes in degenerative spine conditions 2

Functional Restoration Focus

• Emphasize gradual return to activities rather than complete pain elimination 1, 2
• Incorporate cognitive behavioral therapy if pain beliefs interfere with rehabilitation 2
• Address psychosocial factors including depression, anxiety, and catastrophizing that negatively impact outcomes 2

Advanced Conservative Interventions

If initial conservative measures provide insufficient relief after 6 weeks, consider epidural steroid injections only if radicular symptoms develop with nerve root contact on MRI. 1

• Epidural steroid injections provide short-term relief (less than 2 weeks) for radiculopathy but have limited evidence for axial neck pain alone 6
• Facet joint injections can be both diagnostic and therapeutic if facet-mediated pain is suspected 6

Surgical Consideration Criteria

Surgical intervention should only be considered if ALL of the following criteria are met: 1, 2

1. Failure of comprehensive conservative management for at least 3-6 months including formal physical therapy, medication trials, and potentially interventional procedures 1, 2

2. Development of cervical spondylotic myelopathy (CSM) with clinical signs including gait instability, hand clumsiness, hyperreflexia, or positive Hoffman's sign 5, 4

3. Significant functional impairment documented by validated outcome measures (Neck Disability Index, visual analog scale) that persists despite conservative measures 1, 2

4. Radiographic correlation between symptoms and anatomical pathology, particularly cord compression on MRI with T2 hyperintensity indicating myelomalacia 4

Surgical Approach Selection (If Criteria Met)

For patients with CSM requiring surgery, anterior cervical decompression and fusion (ACDF) demonstrates superior long-term outcomes compared to laminectomy alone, with 55% versus 37% good results at long-term follow-up. 5

• Anterior approaches show 73-74% improvement rates for 1-2 level disease 5
• Laminectomy alone carries 29% risk of late neurological deterioration 5
• Laminectomy with fusion shows significantly greater neurological recovery (2.0 Nurick grade improvement) compared to laminectomy alone (0.9 grade improvement) 5
• Better surgical results occur when symptoms are present for less than one year before intervention 5

Critical Pitfalls to Avoid

Do not proceed to surgery based on imaging findings alone without documented clinical correlation and failed conservative management. 1, 2

• Imaging findings of degenerative changes correlate poorly with symptoms in many patients 1, 2
• Straightening of cervical lordosis may be positional or muscular rather than structural 3
• Mild listhesis (anterolisthesis or retrolisthesis) without cord compression rarely requires surgical intervention 3, 4
• Smoking status, depression, and chronic pain syndrome negatively impact surgical outcomes and must be addressed preoperatively 2

Monitoring and Reassessment

Reassess treatment effectiveness at 6 weeks, 3 months, and 6 months using validated outcome measures. 1, 2

• Use Neck Disability Index (NDI) and visual analog scale (VAS) to objectively track progress 1, 2
• Obtain MRI only if progressive neurological symptoms develop or conservative management fails after 3-6 months 1
• Monitor for red flag symptoms including progressive weakness, gait instability, bowel/bladder dysfunction, or severe progressive myelopathy requiring urgent evaluation 5
• Consider surgical consultation only if progressive worsening occurs despite comprehensive conservative management or significant neurological deficits develop 1, 2