Can Retrolisthesis at L4-L5 Cause Left Lower Back Pain?
Yes, retrolisthesis at L4-L5 can absolutely cause left lower back pain, and this is a well-recognized clinical presentation. 1
Primary Pain Pattern in L4-L5 Retrolisthesis
Patients with retrolisthesis at L4-L5 commonly experience chronic low back pain without clear radicular features, which can be localized to one side or bilateral. 1
The pain may be accompanied by vaguely delineated radiating sensations to the lower limbs in approximately 62% of cases, even without frank nerve root compression. 2
Retrolisthesis combined with degenerative changes is particularly associated with abnormal paraspinal muscle electromyographic findings (present in approximately 74% of patients with radiating pain), suggesting mild axonal damage to the posterior branch of the lumbar nerve root that innervates the medial paraspinal muscles. 2
Mechanism of Pain Generation
The backward displacement of L4 on L5 creates mechanical instability and altered biomechanics at that motion segment, which directly contributes to axial back pain. 2
Degenerative retrolisthesis, especially when combined with disc degeneration, is the most common scenario associated with abnormal electromyographic findings showing denervation of the paraspinal muscles. 2
The pain can be unilateral (such as left-sided) due to asymmetric facet joint loading, unilateral muscle dysfunction, or asymmetric degenerative changes at the affected level. 2
Clinical Correlation and Diagnostic Considerations
MRI is the preferred imaging modality to assess soft tissue involvement, disc degeneration, and neural compression in patients with retrolisthesis at L4-L5. 1
If nerve root compression occurs at L4-L5, the L5 nerve root is typically affected, causing sensory loss in the dorsal aspect of the foot and big toe, weakness in foot dorsiflexion and great toe extension, and pain radiating down the lateral leg to the dorsum of the foot. 1
However, many patients with retrolisthesis experience predominantly axial back pain without significant radicular symptoms, particularly when the retrolisthesis is degenerative rather than traumatic. 2, 3
Important Clinical Pitfalls
Do not dismiss localized back pain in the presence of retrolisthesis simply because there are no radicular symptoms—the retrolisthesis itself is a legitimate pain generator. 2
Evaluation should specifically include assessment for degenerative retrolisthesis in patients experiencing radiating sensations with no evidence of frank root impingement, as this represents a distinct clinical entity. 2
The prevalence of retrolisthesis at L4-L5 (or L5-S1) in patients with disc pathology is approximately 23%, and it does not necessarily correlate with worse baseline pain compared to those without retrolisthesis when a disc herniation is also present. 3
Treatment Implications
Rehabilitation should be directed specifically to the medial back muscles because they provide the most effective support for intervertebral motion, and mild disturbances in their innervation are commonly associated with recurrent low back pain in retrolisthesis. 2
Conservative treatment usually suffices for degenerative retrolisthesis, with extended bed rest being of little value. 4
Surgical intervention is reserved for the approximately 15% of patients with clinical signs of cauda equina abnormality, progressive muscular weakness, or progressive incapacitating radicular pain or claudication. 4