Can retrolisthesis (retrograde subluxation of the spine) at the L4-L5 level cause severe back pain, especially in older adults with a history of degenerative spinal changes?

Can Retrolisthesis at L4-L5 Cause Severe Back Pain?

Yes, retrolisthesis at L4-L5 can cause severe back pain, particularly when associated with degenerative changes, though the relationship is complex and influenced by multiple factors.

Evidence Supporting Pain Association

Retrolisthesis combined with degenerative changes significantly worsens pain outcomes. Patients with retrolisthesis and concomitant degenerative disc disease or vertebral endplate changes experience more severe symptoms than those with retrolisthesis alone 1. The mechanism appears related to abnormal intervertebral movement patterns and nerve root irritation at the posterior branch of lumbar nerve roots 1.

Clinical Presentation Patterns

• Radiating pain is common: Approximately 62% of patients with retrolisthesis experience vaguely delineated radiating sensations to the lower limbs, even without frank nerve root compression 1
• Paraspinal muscle denervation occurs: Nearly three-fourths of patients with retrolisthesis and radiating pain show abnormal electromyographic findings consistent with mild axonal damage in the medial paraspinal muscles 1
• Postoperative pain persists: Patients with retrolisthesis who undergo discectomy demonstrate significantly worse bodily pain and physical function scores over 4 years compared to those without retrolisthesis, suggesting the retrolisthesis itself contributes to ongoing pain 2

Biomechanical Context

Retrolisthesis represents a compensatory mechanism for sagittal imbalance rather than simple instability. Patients with retrolisthesis demonstrate significantly lower pelvic incidence, sacral slope, and lumbar lordosis, combined with increased thoracolumbar kyphosis 3. This suggests the posterior vertebral displacement attempts to maintain overall sagittal balance 3.

Degenerative Severity Matters

The degree of disc degeneration influences symptom severity. In patients with retrolisthesis, the average Pfirrmann disk score of 2.11 indicates disks are not severely degenerated at the affected level 3. However, when retrolisthesis occurs with simultaneous degenerative changes, abnormal electromyographic findings showing paraspinal muscle denervation become most common 1.

Risk Factors for Symptomatic Retrolisthesis

Specific patient characteristics increase the likelihood of pain:

• Age-related: Increased age associates with vertebral endplate degenerative changes occurring alongside retrolisthesis 4
• Occupational factors: Workers' compensation status correlates with higher retrolisthesis prevalence, suggesting work-related mechanical stress contributes 4
• Smoking status: Smokers more frequently develop retrolisthesis with concomitant vertebral endplate changes 4

Clinical Implications for L4-L5 Specifically

L4-L5 retrolisthesis warrants careful evaluation because:

• L4 and L3 vertebral retrolisthesis accounts for 35% of movement disturbances in patients with recurrent low back pain 1
• The prevalence of retrolisthesis at lumbar levels reaches 17.1% overall, with L3/4 being the most commonly affected level at 6.8% 5
• Retrolisthesis at L4-L5 typically represents Grade I displacement (less than 25% vertebral body width), but even this degree causes functional impairment 5

Treatment Considerations

Conservative management should target paraspinal muscle rehabilitation. Since mild disturbances in medial back muscle innervation associate with retrolisthesis, rehabilitation directed specifically to these muscles provides the most effective support for intervertebral motion 1.

When to Consider Surgical Intervention

Fusion may be appropriate when retrolisthesis at L4-L5 occurs with documented instability, spondylolisthesis, or when extensive decompression might create iatrogenic instability 6. However, comprehensive conservative management including formal physical therapy for at least 6 weeks to 3 months must be completed first 6, 7.

Common Pitfalls

Do not assume retrolisthesis alone requires fusion. The presence of retrolisthesis was not associated with increased incidence of degenerative disc disease, posterior degenerative changes, or vertebral endplate changes 4. Each pathology must be evaluated independently, and fusion criteria must be met at each level 6.

Imaging findings correlate poorly with symptoms in isolation. The degenerative changes visible on imaging may not be the primary pain source 8. Clinical correlation with physical examination findings and response to conservative treatment determines management 7.