What is the recommended treatment for a patient with retrolisthesis, considering their overall health and potential history of osteoporosis?

Treatment for Retrolisthesis

Conservative management with physical therapy, activity modification, and pain control is the first-line treatment for retrolisthesis, with surgical decompression and fusion reserved for patients with progressive neurological deficits, severe pain refractory to conservative care, or documented spinal instability. 1

Initial Conservative Management

All patients with retrolisthesis should undergo at least 6 weeks of comprehensive conservative treatment before considering surgical intervention. 2 This approach is supported by high-quality evidence demonstrating that most patients with low-grade retrolisthesis (Grade I-II) experience symptom relief without surgery. 1

Conservative Treatment Components

• Physical therapy with core strengthening exercises, stretching, and supervised rehabilitation is the cornerstone of conservative management. 2, 3
• NSAIDs should be used for pain management as first-line pharmacologic therapy. 2, 1
• Epidural steroid injections are recommended for patients with radiculopathy, producing equivalent improvements regardless of stenosis severity. 2
• Activity modification and patient education are essential components of the conservative approach. 2
• Patients should remain active rather than undergo bed rest, as activity is more effective for symptom management. 2
• Chiropractic manipulation, axial distraction, and isometric stretching may provide benefit in selected cases, with evidence showing gradual reduction in retrolisthesis severity over long-term maintenance care. 3

When to Consider Osteoporosis Management

If the patient has a history of osteoporosis or is at risk (postmenopausal women, patients on chronic glucocorticoids), concurrent treatment is essential:

• For adults ≥40 years at moderate-to-high fracture risk, oral bisphosphonates are the first-line treatment (strong recommendation for high risk; conditional for moderate risk). 4
• Calcium 1,000-1,200 mg/day and vitamin D 600-800 IU/day (serum level ≥20 ng/ml) should be provided to all patients. 4
• Alternative agents include IV bisphosphonates, teriparatide, denosumab, or raloxifene (postmenopausal women only) if oral bisphosphonates are not appropriate. 4

Indications for Surgical Intervention

Surgery should be considered only after failure of at least 6 weeks of optimal conservative management and when specific criteria are met. 2, 1

Absolute Indications for Surgery

• Severe or progressive neurologic deficits warrant prompt surgical intervention. 2
• Suspected cauda equina syndrome requires immediate surgical decompression. 2
• Progressive neurological deficits despite conservative care indicate surgical necessity. 1

Relative Indications for Surgery

• Persistent severe pain and functional limitations affecting quality of life after 6 weeks of conservative treatment. 2, 1
• Significant radiculopathy or neurogenic claudication refractory to conservative measures. 2
• Documented spinal instability on flexion-extension radiographs. 5, 1

Surgical Decision-Making Algorithm

Step 1: Determine if Instability is Present

The presence or absence of instability fundamentally changes the surgical approach. 4, 5

• If retrolisthesis is associated with spondylolisthesis of any grade, fusion is indicated in addition to decompression. 5, 1
• If flexion-extension radiographs demonstrate dynamic instability, fusion is recommended. 5
• If stenosis exists without instability or spondylolisthesis, decompression alone is the recommended treatment. 5, 2

Step 2: Assess for Stenosis and Neural Compression

• MRI is the preferred imaging modality to evaluate neural compression, providing superior visualization of soft tissue and the spinal canal. 2
• Upright radiographs with flexion-extension views are essential to identify segmental motion and instability. 2
• Imaging findings must correlate with clinical symptoms for surgical intervention to be appropriate. 6

Step 3: Select Surgical Approach

For retrolisthesis with stenosis but WITHOUT instability:

• Decompression alone is the recommended surgical treatment. 5, 2
• Adding fusion without documented instability increases operative time, blood loss, and surgical risk without proven benefit. 5
• Only 9% of patients without preoperative instability develop delayed slippage after decompression alone. 5

For retrolisthesis with stenosis AND instability/spondylolisthesis:

• Decompression with fusion is strongly recommended, with 96% reporting excellent/good results versus 44% with decompression alone. 6, 5, 2
• Posterolateral fusion with pedicle screw instrumentation is the standard approach. 6, 2
• Pedicle screw fixation improves fusion success rates from 45% to 83% (p=0.0015) compared to non-instrumented fusion. 5
• Transforaminal lumbar interbody fusion (TLIF) or posterior lumbar interbody fusion (PLIF) are appropriate techniques, with fusion rates of 92-95%. 6

Step 4: Consider Risk Factors for Iatrogenic Instability

Fusion should be added when extensive decompression might create instability, even if preoperative instability is not documented. 4, 5

• Extensive decompression without fusion carries a 37.5% risk of late instability development. 5
• Bilateral facetectomy or removal of >50% of facet joints warrants prophylactic fusion. 5
• Multilevel laminectomy significantly increases the risk of postoperative instability, with up to 38% developing iatrogenic destabilization. 5

Special Considerations and Common Pitfalls

Critical Pitfalls to Avoid

• Do not perform fusion for isolated stenosis without evidence of instability—this increases surgical risk without improving outcomes. 5
• Do not skip formal physical therapy—comprehensive conservative management for at least 6 weeks is mandatory before surgical consideration. 6, 2
• Do not rely on static imaging alone—flexion-extension radiographs are essential to identify dynamic instability. 2
• Do not perform multilevel fusion without documenting instability at each level—each level must independently meet fusion criteria. 6

Patient-Specific Factors

• Retrolisthesis is more common in patients with lower pelvic incidence, smaller lumbar lordosis, and increased thoracolumbar kyphosis. 7
• The presence of retrolisthesis alone does not predict worse preoperative pain or function compared to patients without retrolisthesis. 8
• Retrolisthesis appears to serve as a compensatory mechanism for sagittal balance regulation. 7
• Workers' compensation status is associated with higher prevalence of retrolisthesis. 8

Long-Term Monitoring

• Regular radiographic assessment is necessary to evaluate fusion status and monitor for adjacent segment disease. 2
• Monthly maintenance care may be beneficial for patients with relapsing symptoms, with evidence showing gradual reduction in retrolisthesis severity over 13 years. 3
• Complications to monitor include adjacent segment disease, pseudarthrosis, and need for reoperation. 1

Expected Outcomes

• Approximately 97% of patients experience some recovery of symptoms after appropriate surgical intervention. 2
• Decompression with fusion demonstrates superior outcomes in all clinical measures for at least 4 years compared to non-operative management in patients with spondylolisthesis and stenosis. 2
• Patients with stenosis and spondylolisthesis treated with decompression plus fusion report 93-96% excellent/good outcomes versus 44% with decompression alone. 6, 5
• Statistically significant improvements occur in back pain (p=0.01) and leg pain (p=0.002) with fusion compared to decompression alone in patients with instability. 6