Can Retrolisthesis Cause Severe Lumbar Pain?
Yes, retrolisthesis can cause severe lumbar pain, but the relationship is complex and depends on the specific vertebral level and associated degenerative changes.
Evidence for Pain Association
The most compelling evidence comes from studies examining retrolisthesis at different lumbar levels:
Retrolisthesis at L3-L4 is specifically associated with increased lower back pain severity and impaired back function in elderly populations, with statistically significant correlations demonstrated in large cohort studies 1.
Retrolisthesis at L5-S1 shows a more nuanced relationship—while it does not significantly worsen baseline pain or function when a disc herniation is present (likely because disc herniation symptoms overshadow retrolisthesis-related pain), postoperative outcomes reveal that retrolisthesis patients experience significantly worse bodily pain and physical function over 4 years following discectomy 2, 3.
The overall prevalence of retrolisthesis in patients with L5-S1 disc herniation is approximately 23%, indicating it is a relatively common finding in symptomatic populations 2.
Mechanism of Pain Generation
Retrolisthesis causes pain through several biomechanical pathways:
Intervertebral space instability is the primary mechanism, with sagittal imbalance and disc degeneration leading to decreased segmental disc height 4.
When retrolisthesis occurs with concomitant degenerative changes (such as vertebral endplate changes, facet arthropathy, or ligamentum flavum hypertrophy), the cumulative effect can produce severe symptoms requiring surgical intervention 4.
In rare cases, pathologic processes like gouty spondylodiscitis can cause retrolisthesis with severe low back pain and neurological symptoms including intermittent claudication 4.
Clinical Implications and Treatment Considerations
The presence of retrolisthesis should influence surgical planning when decompression is indicated:
Fusion may be warranted when extensive decompression is required in the setting of retrolisthesis, as the existing instability increases the risk of iatrogenic worsening 5, 6.
Conservative management remains the initial treatment approach for degenerative spondylolisthesis (including retrolisthesis), incorporating analgesics, NSAIDs, epidural steroid injections, bracing, and flexion strengthening exercises 7.
Patients with neurological symptoms such as intermittent claudication or vesicorectral disorders will most probably experience neurological deterioration without surgical intervention 7.
Important Caveats
Anterolisthesis (forward slippage) of 3mm or more is relatively common (29% prevalence) in elderly women but is not correlated with back problems, contrasting sharply with retrolisthesis 1.
The contribution of retrolisthesis to pain may be overshadowed when concurrent disc herniation is present, only becoming clinically apparent after the herniation is addressed surgically 2, 3.
Retrolisthesis alone does not increase the incidence of degenerative disc disease, posterior degenerative changes, or vertebral endplate changes, though these conditions frequently coexist 2.