Where is the pain typically located in a patient with retrolisthesis (retrolisthesis) at L4-L5 (lumbar vertebrae 4-5)?

Pain Location in L4-L5 Retrolisthesis

Retrolisthesis at L4-L5 typically causes localized low back pain, with potential radiating sensations to the lower limbs that are often vague and poorly defined, rather than classic radicular patterns.

Primary Pain Patterns

Localized Low Back Pain

• The predominant symptom is axial low back pain centered at the L4-L5 level 1
• Pain originates from the posterior displacement of L4 relative to L5, creating mechanical instability and stress on surrounding structures 1
• Patients with retrolisthesis at L4-L5 commonly experience chronic low back pain without clear radicular features 2

Radiating Pain Characteristics

• Vaguely delineated radiating sensations to the lower limbs occur in approximately 62% of patients with retrolisthesis 1
• These radiating symptoms differ from classic radiculopathy—they are poorly localized and do not follow specific dermatomal patterns 1
• The radiating pain results from mild axonal damage to the posterior branch of lumbar nerve roots innervating the medial paraspinal muscles, rather than ventral root compression 1

Neurological Considerations

L4-L5 Nerve Root Involvement

• When nerve root compression does occur at L4-L5, the L5 nerve root is typically affected, causing:
  • Sensory loss in the dorsal aspect of the foot and big toe 3
  • Weakness in foot dorsiflexion and great toe extension 3
  • Pain radiating down the lateral leg to the dorsum of the foot 3

Distinguishing Features from Anterolisthesis

• Unlike anterolisthesis (forward slippage), which commonly causes foraminal nerve compression and clear radicular symptoms, retrolisthesis more often produces referred pain patterns without definitive root impingement 4, 1
• Retrolisthesis at L4-L5 is associated with degenerative changes and abnormal back muscle electromyographic findings showing denervation of paraspinal muscles 1

Clinical Pitfalls

Common Diagnostic Errors

• Do not expect classic dermatomal pain patterns—the radiating sensations are typically vague and non-specific 1
• Absence of clear radicular findings does not rule out significant pathology; paraspinal muscle denervation may be the primary finding 1
• Retrolisthesis at L4-L5 often coexists with degenerative disc disease, which contributes to the pain syndrome 1, 5

Anatomical Considerations

• More coronal facet joint orientation at L4-L5 predisposes to retrolisthesis when disc degeneration occurs 5
• This anatomical variant explains why retrolisthesis at L4-L5 commonly develops above isthmic spondylolisthesis at L5-S1 5

Imaging Correlation

• Dynamic radiographs showing retrolisthesis at L4-L5 should prompt evaluation for degenerative changes 1
• MRI remains the preferred imaging modality to assess soft tissue involvement, disc degeneration, and neural compression 2, 3
• Electromyographic studies may reveal paraspinal muscle denervation even when imaging shows no clear nerve root compression 1