Initial Treatment for Anterolisthesis
Conservative management with physical therapy emphasizing flexion-based exercises is the initial treatment for anterolisthesis, and should be attempted for at least 6 weeks before considering surgical intervention. 1, 2, 3, 4
Conservative Management Protocol
First-Line Treatment Components
Physical therapy is the cornerstone of initial management, focusing specifically on flexion-based back strengthening exercises rather than extension exercises, as flexion exercises demonstrate superior outcomes with 62% recovery rates at 3 years versus 0% for extension exercises 5
Non-narcotic pain medications (NSAIDs) should be initiated as first-line pharmacologic management 3, 4
Neuropathic pain medications (gabapentin or pregabalin) should be trialed if radicular symptoms are present 6
Epidural steroid injections or transforaminal injections can provide short-term relief for patients with radiculopathy, though duration of relief is typically less than 2 weeks 6, 3, 4
Specific Physical Therapy Approach
Flexion or isometric back strengthening exercises should be prescribed, as these demonstrate significantly better outcomes than extension exercises (58% recovery at 3 months versus 6% with extension exercises) 5
Abdominal and back muscle strengthening exercises are essential components 7
Hamstring and hip flexor stretching exercises should be incorporated to address muscle tightness 8, 7
Postural training and proper lifting technique education must be included 5
Duration and Monitoring
Conservative management should be attempted for at least 6 weeks before considering surgical intervention, though some guidelines suggest 3-6 months for optimal trial 1, 6, 2
Persistent or progressive symptoms after 6 weeks of optimal conservative management indicate the need for surgical evaluation 2
When Conservative Management Fails
Indications for Surgical Consideration
Decompression with fusion is superior to decompression alone for spondylolisthesis with radiculopathy, with 96% reporting excellent/good outcomes versus 44% with decompression alone 1, 2
Significant neurological symptoms including radiculopathy and functional limitations affecting quality of life warrant surgical evaluation 2
The presence of any degree of spondylolisthesis with stenosis requiring decompression is a Grade B indication for fusion 1, 6
Critical Pitfalls to Avoid
Do not prescribe extension-based exercises for patients with anterolisthesis, as these demonstrate poor outcomes with 67% having moderate-to-severe pain at 3 years versus 19% with flexion exercises 5
Do not proceed directly to surgery without documented failure of comprehensive conservative management including formal supervised physical therapy for at least 6 weeks 1, 6, 2
Do not perform decompression alone in patients with documented spondylolisthesis, as this leads to significantly worse outcomes compared to decompression with fusion 1, 2
Special Populations
For pediatric patients (ages 5-14), thoracolumbosacral orthotic bracing worn all day except bedtime until symptoms resolve, followed by physiotherapy, achieves excellent outcomes in 80% of cases 7
Elderly patients may require modified exercise programs focusing on pain reduction, range of motion improvement, and quality of life enhancement 8