What is the best course of treatment for a patient with straightening of cervical lordosis, grade 1 retrolisthesis at C5, and advanced degenerative spondylosis at C4-C5?

Treatment of Cervical Lordosis Straightening, Grade 1 Retrolisthesis C5, and Advanced Degenerative Spondylosis C4-C5

Initial management should be conservative with structured physical therapy, cervical traction, and analgesics for at least 3-6 months unless neurological deficits or progressive myelopathy are present, in which case anterior cervical decompression and fusion is the definitive treatment. 1, 2

Conservative Management (First-Line for Asymptomatic or Mild Symptoms)

When to use conservative treatment:

• Absence of myelopathy (no gait disturbance, hand clumsiness, or bowel/bladder dysfunction) 1
• Absence of progressive neurological deficits 3
• Radicular symptoms that are mild to moderate in severity 1

Specific conservative interventions:

• Structured cervical extension traction combined with extension exercises can restore lordosis even in advanced degenerative disease, with documented improvements of 27° in global C2-C7 lordosis 4
• Intermittent motorized cervical traction combined with spinal manipulation for 3 months has shown complete symptom relief and restoration of cervical lordosis at 4-year follow-up 5
• Analgesics and selective nerve root injections for radicular pain control 1
• Conservative treatment requires regular review (every 2-4 weeks) with careful medication selection on a case-by-case basis 1

Surgical Indications (When Conservative Treatment Fails or Contraindicated)

Proceed directly to surgery if:

• Moderate to severe myelopathy is present (Nurick grade 2 or higher) 1, 2
• Progressive neurological deterioration occurs despite conservative management 3
• Instability demonstrated on flexion/extension radiographs (>3.5mm translation or >11° angulation) 3
• Conservative treatment fails after 3-6 months with persistent disabling symptoms 1, 2

Surgical Approach for Cervical Degenerative Spondylolisthesis with Advanced Spondylosis

Anterior cervical decompression and fusion (ACDF) is the gold standard surgical treatment for this specific pathology, with 92% fusion rates and average neurologic improvement of 1.5 Nurick grades at 6.9-year follow-up. 2

Surgical technique specifics:

• Corpectomy of the caudal vertebra (C5) is most commonly required when advanced spondylosis is present at the retrolisthesis level 2
• Structural iliac crest graft or interbody cage with anterior plate fixation provides immediate stability 2
• Extension to adjacent levels (C4-C6 fusion) is necessary when multilevel degeneration or instability exists 3, 2
• Combined anterior-posterior fusion is reserved for cases with additional dorsal spinal cord compression or when anterior-only approach cannot achieve adequate decompression (required in approximately 5% of cases) 3, 2

Critical Decision Points Based on Radiographic Findings

The degree of correction possible by positioning determines surgical strategy:

• If spondylolisthesis reduces with extension positioning: single-level or two-level ACDF with cage and plate is sufficient 3
• If severe fixed spondylosis prevents reduction: corpectomy is necessary 3
• If dorsal compression coexists with ventral pathology: combined anterior-posterior approach is required 3

Pitfalls to Avoid

Do not perform laminoplasty or posterior decompression alone for anterior pathology with retrolisthesis, as this creates iatrogenic instability and leads to progressive kyphotic deformity 6, 7

Do not delay surgery beyond 6 months in patients with documented myelopathy, as prolonged cord compression reduces the potential for neurological recovery 1, 2

Do not assume that advanced degenerative changes preclude non-surgical correction - structured extension traction protocols can improve lordosis even with advanced osteoarthritis if no myelopathy exists 4

Prognosis and Expected Outcomes

With appropriate surgical management:

• 92% achieve solid fusion 2
• 75% demonstrate neurological improvement (6 of 8 myelopathy patients, 4 of 5 radiculomyelopathy patients) 3
• 100% achieve pain relief when pain was the primary complaint 3
• Average follow-up demonstrates stable results at 6.9 years 2

The development of kyphosis predicts poor outcomes (p < 0.05), making restoration or preservation of lordosis a critical surgical goal. 6, 7