What is the recommended treatment for a patient with grade 1 retrolisthesis?

Treatment for Grade 1 Retrolisthesis

For grade 1 retrolisthesis, initial treatment should consist of supervised exercise programs focusing on paraspinal and abdominal muscle strengthening for at least 3-6 months, with surgery reserved only for patients who develop significant neurological symptoms, progressive instability, or fail conservative management. 1

Initial Conservative Management (First-Line Treatment)

• Begin with supervised exercise programs that specifically target paraspinal and abdominal muscles to provide better spinal support 1
• Continue conservative therapy for a minimum of 3-6 months before considering surgical intervention 1
• Conservative options may include physical therapy, epidural steroid injections (though relief typically lasts less than 2 weeks), and pain medications 2, 3
• Chiropractic maintenance care with cervical manipulation, axial distraction, and isometric stretching has shown effectiveness in reducing retrolisthesis over long-term follow-up 4

Important caveat: Grade 1 retrolisthesis alone, without associated stenosis or instability, does not correlate with increased preoperative pain or functional impairment compared to patients without retrolisthesis 5. This means the retrolisthesis itself may not be the primary pain generator.

When to Consider Surgical Intervention

Surgery becomes appropriate only when all three of the following criteria are met:

• Failure of conservative management for at least 3-6 months 1
• Significant neurological symptoms (progressive weakness, sensory deficits, or radiculopathy) 1
• Documented instability on flexion-extension radiographs or associated spinal stenosis 6, 1

Surgical Decision Algorithm

If retrolisthesis WITHOUT stenosis or instability:

• Decompression alone may be sufficient 1
• Fusion is NOT recommended, as there is no evidence it improves outcomes in isolated retrolisthesis without deformity or instability 6

If retrolisthesis WITH spinal stenosis but NO instability:

• Decompression alone is appropriate 6, 1
• Adding fusion does not provide additional benefit 6

If retrolisthesis WITH significant instability OR spondylolisthesis:

• Decompression with fusion is recommended 6, 1
• Class II evidence shows 96% excellent/good results with decompression plus fusion versus only 44% with decompression alone in patients with stenosis and instability 6

If retrolisthesis WITH kyphosis or excessive motion:

• Pedicle screw fixation should be considered 1
• Instrumented fusion provides optimal biomechanical stability with fusion rates up to 95% 2

Special Clinical Considerations

• Progressive neurological deficits should prompt urgent surgical evaluation regardless of conservative treatment duration 1
• Traumatic retrolisthesis (from falls or high-energy trauma) requires early surgical decompression and stabilization, as these injuries are highly unstable 7, 8
• Workers' compensation patients with retrolisthesis may have different outcomes, as they are more likely to have retrolisthesis than non-compensation patients 5
• Chronic low back pain refractory to conservative treatment may warrant fusion consideration, but only after comprehensive conservative management including formal physical therapy for at least 6 weeks 2

Common Pitfalls to Avoid

• Do not perform fusion for isolated grade 1 retrolisthesis without documented instability or stenosis—there is no evidence supporting routine fusion, and it increases costs and complications without improving outcomes 6, 2
• Do not rush to surgery—the natural history of degenerative retrolisthesis often responds to conservative management 3
• Do not assume retrolisthesis is the pain source—in patients with concomitant disc herniation, the disc pathology typically overshadows any contribution from retrolisthesis 5
• Ensure adequate conservative treatment before surgery—incomplete physical therapy or inadequate trial of conservative measures does not meet medical necessity criteria for fusion 2