What is the recommended treatment for a 32-year-old male patient with lumbar pain, diagnosed with Grade 1-2 anterolisthesis of L5 relative to S1 with suspected associated spondylolyses?

Treatment for Grade 1-2 Anterolisthesis of L5 on S1 with Suspected Spondylolysis

Begin with a comprehensive 6-week to 3-month trial of conservative management including formal physical therapy, NSAIDs, and activity modification before considering surgical intervention. 1

Initial Conservative Management (First-Line Treatment)

Conservative treatment should be the initial approach for this 32-year-old male with Grade 1-2 anterolisthesis and suspected spondylolysis, as the natural history of degenerative spondylolisthesis is generally favorable. 2

Required Conservative Measures:

• Formal physical therapy for at least 6 weeks, focusing on core strengthening and flexion-based exercises 1
• NSAIDs and analgesics for pain control during the conservative treatment period 2
• Activity modification with avoidance of lumbar extension activities that exacerbate symptoms 3
• Epidural steroid injections may provide short-term relief (less than 2 weeks) but do not constitute adequate conservative management alone 1
• Bracing can be considered as an adjunct, particularly for younger patients with acute symptoms 2, 4

The prognosis with conservative management is favorable for most patients, though those with progressive neurological symptoms may require surgical intervention. 2

Advanced Imaging to Confirm Diagnosis

Since plain radiographs have only 77.6% sensitivity for spondylolysis, obtain MRI of the lumbar spine to confirm the suspected spondylolysis and assess for active stress reaction versus established fracture. 5

• MRI is superior to radiographs for detecting active spondylolysis and can show bone marrow edema in the pars interarticularis, which correlates with clinical symptoms 5
• CT scan can be obtained as an adjunct if MRI shows equivocal findings, as it has high sensitivity for evaluating established pars defects 5
• Flexion-extension radiographs should be obtained to assess for dynamic instability if surgical intervention is being considered 6

Indications for Surgical Intervention

Surgery should only be considered after failure of comprehensive conservative management for 3-6 months and when specific criteria are met. 1, 6

Surgical Criteria (All Must Be Present):

• Persistent disabling symptoms despite adequate conservative treatment including formal physical therapy 1, 6
• Documented instability on flexion-extension radiographs or progressive slip on serial imaging 5, 1
• Neurological symptoms including radiculopathy, neurogenic claudication, or progressive motor weakness 3, 6
• Imaging findings that correlate with clinical symptoms and functional impairment 1, 3

Surgical Approach When Indicated:

Decompression with instrumented fusion is superior to decompression alone for symptomatic spondylolisthesis, with 93-96% of patients reporting excellent/good outcomes versus only 44% with decompression alone. 5, 1, 6

• Posterolateral fusion (PLF) with pedicle screw instrumentation provides optimal biomechanical stability with fusion rates up to 95% 5, 1
• Transforaminal lumbar interbody fusion (TLIF) is an appropriate technique offering high fusion rates (92-95%) while allowing simultaneous decompression 1, 6
• The choice between PLF and interbody techniques should be based on surgeon preference and patient anatomy, as no significant outcome differences exist between fusion techniques when appropriately selected 5

Critical Pitfalls to Avoid

• Do not proceed to surgery without completing formal physical therapy for at least 6 weeks, as this represents inadequate conservative management 1
• Do not rely on epidural injections alone as they provide only temporary relief and do not satisfy conservative treatment requirements 1
• Do not perform fusion for isolated spondylolysis without documented instability or neurological symptoms, as conservative management is highly successful in these cases 4, 7
• Do not overlook coexisting pathology such as disc degeneration, facet arthropathy, or adjacent level stenosis that may contribute to symptoms 3

Expected Outcomes with Appropriate Management

Conservative management leads to satisfactory outcomes in the majority of patients with low-grade spondylolisthesis without progressive neurological symptoms. 2, 4, 7 For those requiring surgery after failed conservative treatment, decompression with fusion provides superior long-term outcomes with statistically significant improvements in back pain (p=0.01) and leg pain (p=0.002) compared to decompression alone, maintained for at least 4 years. 5, 6