What is the recommended treatment for a patient with retrolisthesis?

Treatment for Retrolisthesis

Conservative management with supervised exercise programs focusing on paraspinal and abdominal strengthening should be the initial treatment for retrolisthesis, with surgery reserved only for cases with significant neurological symptoms, progressive instability, or failure of at least 3-6 months of comprehensive conservative therapy. 1

Initial Conservative Management (First-Line Treatment)

All patients with retrolisthesis should begin with conservative therapy unless red flags are present. 2 The treatment approach mirrors that for degenerative spondylolisthesis:

• Supervised exercise programs that specifically target paraspinal and abdominal muscle strengthening provide better spinal support and should be the cornerstone of initial management 1
• Formal physical therapy for at least 6 weeks is required before considering any surgical intervention 2, 3
• NSAIDs and analgesics for pain control are appropriate initial pharmacologic options 4
• Epidural steroid injections may provide short-term relief (typically less than 2 weeks) for radicular symptoms, though evidence for chronic axial back pain without radiculopathy is limited 3
• Bracing and flexion strengthening exercises can be incorporated as physical treatment modalities 4

The prognosis with conservative management is generally favorable, though patients with neurological symptoms such as intermittent claudication may experience deterioration without surgical intervention 4.

When to Consider Surgical Intervention

Surgery should only be considered after failure of conservative management for at least 3-6 months AND when specific criteria are met: 1, 3

Absolute Indications for Surgery:

• Significant neurological deficits, especially progressive ones, warrant urgent surgical evaluation 1
• Traumatic retrolisthesis with nerve root compression requires early decompression and instrumented fusion 5
• Documented spinal instability on flexion-extension radiographs combined with symptomatic stenosis 6

Relative Indications (All Must Be Present):

• Failure of comprehensive conservative therapy including formal supervised physical therapy for 3-6 months 1, 3
• Imaging findings that correlate with clinical symptoms, particularly moderate-to-severe stenosis with neural compression 6, 3
• Significant functional impairment persisting despite conservative measures 3

Surgical Approach Selection

The surgical strategy depends on the presence or absence of instability and associated pathology:

For Retrolisthesis WITH Stenosis but WITHOUT Instability:

• Decompression alone may be sufficient 1, 6
• Fusion is NOT routinely indicated in the absence of documented instability 6

For Retrolisthesis WITH Significant Instability or Spondylolisthesis:

• Decompression with fusion is recommended 1, 6
• Class II evidence demonstrates 96% excellent/good outcomes with decompression plus fusion versus only 44% with decompression alone in patients with stenosis and spondylolisthesis 3
• Pedicle screw fixation should be considered in cases with kyphosis or excessive motion at the retrolisthesis site, as it improves fusion success rates from 45% to 83% 1, 6

For Chronic Low Back Pain Due to Retrolisthesis:

• Lumbar fusion may be appropriate only after refractory conservative treatment and when there is documented instability or degenerative disc disease 1, 3

Critical Pitfalls to Avoid

• Do not perform fusion for isolated stenosis without documented instability - this increases surgical risk without proven benefit 6, 3
• Do not skip comprehensive conservative management - at least 6 weeks of formal supervised physical therapy is mandatory before surgical consideration 2, 3
• Do not rely on static imaging alone - flexion-extension radiographs are essential to identify segmental motion and instability 2
• Avoid extensive decompression without fusion when instability is present - this carries a 38% risk of iatrogenic instability 6

Special Considerations

• Progressive neurological deficits should prompt more urgent surgical evaluation regardless of conservative treatment duration 1
• Traumatic retrolisthesis represents a distinct entity requiring early surgical decompression and stabilization 5
• Long-term maintenance care with monthly chiropractic manipulation has been reported to reduce cervical retrolisthesis in case reports, though this represents low-level evidence 7
• MRI is the initial imaging modality of choice for patients who have failed 6 weeks of conservative therapy and are surgical candidates 2