How to manage a patient with mild retrolisthesis?

Management of Mild Retrolisthesis

For mild retrolisthesis without significant instability or neurological symptoms, conservative management with flexion-based exercises should be the primary treatment approach, reserving surgical intervention only for cases with documented instability on dynamic imaging or failed comprehensive conservative therapy lasting at least 3-6 months. 1, 2

Initial Conservative Management (First-Line Treatment)

Conservative therapy should be attempted for a minimum of 3-6 months before considering any surgical options. 2, 3

Exercise-Based Therapy

• Flexion exercises are superior to extension exercises for symptomatic retrolisthesis, with only 19% of patients having moderate-to-severe pain at 3-year follow-up compared to 67% in extension exercise groups 4
• The flexion program should include abdominal curl-ups, posterior pelvic tilts, and seated trunk flexion performed consistently 4
• Recovery rates with flexion exercises reach 62% at 3 years versus 0% with extension exercises 4
• Formal physical therapy for at least 6 weeks is required before escalating treatment 5, 2

Multimodal Conservative Approach

• Anti-inflammatory medications should be initiated as part of comprehensive pain management 2, 3
• Neuroleptic medications (gabapentin or pregabalin) should be started early if radicular symptoms develop 2
• Epidural steroid injections may provide short-term relief for radiculopathy, though evidence is limited for isolated axial back pain 2
• Instruction in proper body mechanics and ergonomics is essential 3
• Deep-heat therapy can be used for symptomatic relief 3

Chiropractic and Manual Therapy Considerations

• Long-term chiropractic maintenance care with cervical manipulation, axial distraction, and isometric stretching has demonstrated gradual reduction in retrolisthesis over 13 years in case reports 6
• Monthly maintenance programs including manipulation of dysfunctional segments and strengthening exercises may prevent symptom recurrence 6

Monitoring and Reassessment

Timeline for Evaluation

• Evaluate response at 6 weeks to determine if escalation to interventional procedures is needed 2
• Reassess at 3 months to determine if surgical consultation is appropriate for persistent symptoms 2, 3
• Magora recommends 3-4 months as the minimal trial period for conservative treatment 3

Imaging Requirements

• Obtain flexion-extension radiographs if instability is suspected, as movement on dynamic films changes management from conservative to surgical 1, 2
• MRI is the initial imaging modality for patients with radiculopathy who have failed conservative therapy 2, 7
• Upright radiographs with flexion-extension views are essential to identify segmental motion and instability 2, 7

Surgical Indications (When Conservative Management Fails)

Surgery should only be considered when specific criteria are met—mild retrolisthesis alone is NOT an indication for fusion. 1

Absolute Requirements for Surgical Consideration

• Documented instability on flexion-extension radiographs with movement at the affected level 1, 2
• Failed comprehensive conservative management for at least 3-6 months 5, 2, 8
• Persistent disabling symptoms with significant functional impairment affecting quality of life 2, 7
• Imaging findings that correlate directly with clinical symptoms 5

Evidence Against Routine Fusion

• In the absence of deformity or instability, lumbar fusion has not been shown to improve outcomes in patients with isolated stenosis (Grade B evidence) 5
• There is no convincing medical evidence to support routine fusion without significant instability 5
• Decompression alone may be sufficient if no instability is present 1, 5

When Fusion IS Indicated

• Decompression with fusion is superior to decompression alone when retrolisthesis is associated with documented instability, with 96% reporting excellent/good results versus 44% with decompression alone 1, 2
• Patients treated with decompression/fusion have statistically significantly less back pain (p=0.01) and leg pain (p=0.002) compared to decompression alone 1
• Class II medical evidence supports fusion following decompression in patients with lumbar stenosis and instability evidenced by movement on preoperative flexion-extension radiographs 1

Critical Pitfalls to Avoid

Overtreatment Risks

• Do not perform fusion for mild retrolisthesis without documented instability on dynamic imaging—this represents overtreatment with increased complications and costs without proven benefit 1, 5
• The definite increase in cost and complications associated with fusion are not justified in cases lacking clear instability criteria 5
• Fusion procedures carry higher complication rates (31-40%) compared to decompression alone (6-12%) 5

Inadequate Conservative Management

• Failure to complete formal physical therapy for at least 6 weeks is a critical deficiency that precludes surgical consideration 5
• Extension exercises may worsen outcomes—ensure flexion-based programs are prescribed 4
• Inadequate assessment of instability on static imaging alone may miss dynamic instability that becomes evident on flexion-extension films 1

Traumatic Retrolisthesis Exception

• Traumatic retrolisthesis with acute disc extrusion and neurological deficit requires urgent surgical decompression and stabilization—this is a completely different entity than degenerative mild retrolisthesis 9
• Early decompression followed by circumferential instrumentation results in dramatic neurologic improvement in traumatic cases 9

Expected Outcomes with Conservative Management

• 58% recovery rate at 3 months with flexion exercises, improving to 62% at 3 years 4
• Only 19% of patients doing flexion exercises have moderate-to-severe pain at 3-year follow-up 4
• Only 24% of flexion exercise patients are unable to work or have limited work at 3 years 4
• Patients treated with flexion programs are less likely to require back supports, job modifications, or activity limitations 4
• Complete relief of symptoms and full mobility can be achieved with multimodal chiropractic care in appropriate cases 6