What is the recommended management approach for an older adult patient with a history of back pain, presenting with radiological findings of minimal dextroscoliosis, minimal spondylosis, Grade 1/4 L4-5 anterolisthesis, and disc space narrowing at various lumbar levels?

Management of Degenerative Lumbar Spine Disease with Grade 1 Anterolisthesis

Initial Conservative Management is Required

Conservative treatment for a minimum of 3-6 months is mandatory before considering surgical intervention for this radiographic presentation, unless progressive neurological deficits develop. 1

The radiographic findings described—minimal dextroscoliosis, minimal spondylosis, Grade 1/4 L4-5 anterolisthesis, and multilevel disc space narrowing—represent common degenerative changes in older adults that frequently occur without causing significant symptoms. 2 The presence of these findings alone does not justify surgical intervention without documented failure of comprehensive conservative management. 3, 1

Required Conservative Treatment Components

Before any surgical consideration, the following must be completed and documented:

• Formal physical therapy for minimum 6 weeks with documented attendance logs and therapist progress notes showing supervised, structured therapy—not just home exercises. 3, 1

• Trial of neuroleptic medications (gabapentin or pregabalin) for neuropathic pain management if radicular symptoms are present. 3, 1

• Anti-inflammatory therapy with NSAIDs or COX-2 inhibitors unless contraindicated. 3

• Epidural steroid injections should be considered for radiculopathy from foraminal stenosis before proceeding to surgery, with documentation of patient response. 1

The total duration of conservative management must span at least 3-6 months with documented compliance and treatment failure before surgical options become appropriate. 3, 1

Clinical Correlation is Essential

Imaging findings must correlate directly with clinical symptoms—radiographic abnormalities alone do not justify treatment. 1, 4

Grade 1 anterolisthesis (up to 25% vertebral body displacement) is frequently asymptomatic and represents a common finding in the aging spine. 5, 6 Disc space narrowing is present in 75.8% of individuals over age 60, with severe changes in 50.4%, yet only 28.8% report low back pain. 2 This disconnect between imaging and symptoms underscores that treatment decisions must be driven by clinical presentation, not radiographic findings.

Surgical Indications Only After Conservative Failure

Surgical intervention becomes appropriate only when ALL of the following criteria are met:

• Documented instability or spondylolisthesis causing persistent disabling symptoms despite 3-6 months of comprehensive conservative management. 3

• Imaging findings that correlate directly with clinical symptoms—the level of radiographic pathology must match the distribution of pain and neurological findings. 1, 4

• Significant functional impairment persisting despite conservative measures, with objective documentation of disability. 3

• Spinal stenosis requiring decompression that coincides with the spondylolisthesis, as fusion is specifically indicated when extensive decompression might create iatrogenic instability. 3

For Grade 1 anterolisthesis at L4-5 specifically, decompression combined with fusion provides superior outcomes (96% excellent/good results) compared to decompression alone (44% excellent/good results) when stenosis is present and conservative management has failed. 3 However, in the absence of stenosis or instability, fusion has not been shown to improve outcomes. 3

Critical Pitfalls to Avoid

• Do not proceed to surgery based solely on radiographic findings without documented conservative treatment failure—this leads to poor outcomes and unnecessary procedures. 1, 4

• Do not assume prior spine surgery history exempts the patient from conservative treatment requirements—it does not. 1

• Do not misinterpret disc space narrowing as equivalent to nerve compression—patent canal and foramina indicate absence of compression. 4

• Do not perform fusion for isolated disc degeneration without stenosis or instability—Level III evidence shows no significant difference in outcomes between decompression alone versus decompression with fusion in these cases. 4

Monitoring During Conservative Treatment

During the 3-6 month conservative period, monitor for:

• Progressive neurological deficits (weakness, sensory loss, bowel/bladder dysfunction)—these constitute red flags requiring urgent surgical evaluation regardless of conservative treatment duration. 3

• Response to physical therapy with objective functional measures (Oswestry Disability Index, pain scales, walking distance). 3

• Medication efficacy and side effects, adjusting regimens as needed. 1

• Development of severe stenosis symptoms such as neurogenic claudication limiting ambulation to less than one block. 3

If conservative management provides adequate symptom control, continue non-operative treatment indefinitely with periodic reassessment. 6 Surgical intervention is reserved exclusively for those with persistent disabling symptoms after documented conservative failure and clear correlation between imaging findings and clinical presentation. 3, 1