Initial Treatment for Grade 1 Retrolisthesis of L5 on S1
Conservative management with physical therapy for at least 6 weeks is the initial treatment for grade 1 retrolisthesis of L5 on S1 without red flag symptoms. 1, 2
Conservative Management Protocol
Begin with a structured 6-week physical therapy program that includes core strengthening exercises, hamstring stretching, and spine range of motion activities, combined with restriction of aggravating activities. 3 This approach achieves pain relief and restoration of function in 96% of patients with grade 1 spondylolisthesis, with 78% reporting complete resolution of symptoms. 3
Key Components of Initial Treatment:
Physical therapy should focus on core stabilization, hamstring flexibility, and controlled spine mobility exercises for a minimum of 6 weeks. 2, 3
Activity modification by avoiding lumbar extension activities and movements that worsen symptoms (standing, walking, or extension typically aggravate pain). 4
Pharmacologic management including anti-inflammatory medications and consideration of neuropathic pain medications (gabapentin or pregabalin) if radicular symptoms are present. 2
Bracing is NOT required for successful conservative management of grade 1 retrolisthesis, as non-bracing techniques achieve equivalent outcomes while avoiding compliance issues and costs. 3
When to Image
Do NOT obtain imaging initially unless red flag symptoms are present. 1 Routine imaging provides no clinical benefit in uncomplicated low back pain and leads to increased healthcare utilization without improving outcomes. 1
Red Flag Symptoms Requiring Immediate MRI:
- Bladder or bowel dysfunction (cauda equina syndrome). 4
- Saddle anesthesia. 4
- Bilateral severe lower extremity weakness. 4
- Progressive neurological deficits. 4
Progression to Advanced Imaging
MRI lumbar spine without contrast becomes appropriate only after 6 weeks of failed conservative therapy if the patient is a surgical candidate or diagnostic uncertainty remains. 1, 2 The goal is to identify actionable pain generators that could be targeted for intervention. 1
Imaging Considerations After Conservative Failure:
MRI is the initial imaging modality of choice for evaluating nerve root compression, disc pathology, and spinal stenosis after conservative treatment failure. 1
Flexion-extension radiographs should be obtained to assess for dynamic instability, which is critical for surgical planning in spondylolisthesis cases. 1
Critical Pitfalls to Avoid
Do not correlate imaging findings alone without clinical symptoms, as disc abnormalities are common in asymptomatic patients. 4
Do not overlook coexisting pathology such as facet arthropathy, synovial cysts, or adjacent level stenosis that may contribute to symptoms. 4
Do not rush to imaging in the absence of red flags, as this increases costs without improving outcomes and may lead to unnecessary interventions. 1
Expected Outcomes
Conservative management is highly effective for grade 1 retrolisthesis, with 96% of patients achieving minimal disability scores and the majority experiencing complete symptom resolution. 3 Grade 1 retrolisthesis is considered a self-limiting condition responsive to medical management and physical therapy in most patients. 1