What is the best management approach for a patient with cervical anterolisthesis (forward displacement of a vertebra) and neck pain?

Management of Cervical Anterolisthesis with Neck Pain

Initial Conservative Management is Strongly Recommended

Conservative treatment should be the first-line approach for cervical anterolisthesis with neck pain, as most patients improve without surgery, and surgical intervention is reserved only for those with progressive neurological deficits, myelopathy, or failure of conservative measures after 6-8 weeks. 1, 2, 3

Assessment for Red Flags (Immediate Evaluation Required)

Before initiating conservative care, you must screen for conditions requiring urgent intervention:

• Constitutional symptoms (fever, unexplained weight loss, night sweats) suggesting infection or malignancy 1, 4
• Progressive or severe neurological deficits indicating cord compression or nerve root compromise 1, 4
• Signs of myelopathy (hyperreflexia, Babinski sign, gait disturbance, bowel/bladder dysfunction) 4, 3
• Risk factors for infection (IV drug use, immunosuppression, elevated ESR/CRP) 1, 4
• History of malignancy or trauma with high-energy mechanism 1, 4

If any red flags are present, obtain MRI immediately to rule out epidural abscess, metastatic disease, or acute cord compression. 4

Initial Imaging Strategy

• Plain radiographs (AP, lateral, and flexion-extension views) are appropriate initially to assess vertebral alignment, hardware integrity if post-surgical, and dynamic instability 5
• MRI is NOT indicated initially unless red flags are present, as degenerative findings are present in 85% of asymptomatic individuals over 30 and do not correlate with symptoms 1, 4
• Reserve MRI for patients with persistent symptoms beyond 6-8 weeks or those being considered for surgical intervention 1, 2

Conservative Treatment Protocol (First 6-8 Weeks)

Pharmacologic Management

• Analgesics and NSAIDs for pain control 6
• Neuropathic pain medications (gabapentin, pregabalin) if radicular symptoms are present 6
• Short-term muscle relaxants may be considered for acute muscle spasm 6

Physical Modalities

• Avoid prolonged cervical collar use beyond short-term immobilization (48-72 hours maximum), as collars can lead to muscle deconditioning 7, 6
• Physical therapy focusing on range of motion, strengthening, and postural correction 2, 6
• Cervical traction may provide temporary symptom relief but evidence is limited 6
• Multimodal approach combining medications, physical therapy, and activity modification typically yields best results 6

Critical Prognostic Factor: Baseline Anterolisthesis

The presence of cervical anterolisthesis is a significant negative prognostic indicator that predicts persistent neck pain and poorer functional outcomes, even after surgical intervention. 8

• Patients with anterolisthesis have the highest odds ratio for persistent moderate-to-severe neck pain at 2-year follow-up 8
• Other predictors of poor outcome include current smoking, moderate-to-severe baseline neck pain (≥4/10), and lower mental health scores 8
• This information is crucial for setting realistic patient expectations regarding recovery 8

Surgical Indications (After Failed Conservative Care)

Surgery should be considered only in specific circumstances:

For Radiculopathy

• Failure of 6-8 weeks of conservative treatment with persistent radicular symptoms 2, 3
• Significant or progressive neurological deficits at presentation 3
• Anterior cervical discectomy with fusion (ACDF) is the standard surgical approach for single or two-level disease 5

For Myelopathy

• Earlier surgical consideration is appropriate for myelopathy, though mild cases can still be observed with conservative treatment 3
• Progressive myelopathy warrants prompt surgical decompression to prevent irreversible cord damage 2, 3

For Axial Neck Pain Alone

• Surgery is generally NOT recommended for isolated axial neck pain without radiculopathy or myelopathy 3
• Rare exceptions include single or two-level degenerative disc disease with severe, unrelenting pain after exhaustive conservative measures 3
• In the specific context of anterolisthesis with persistent pain and progressive instability, anterior interbody fusion may be considered, though outcomes are less predictable 9

Surgical Technique Considerations (If Surgery Required)

• ACDF provides more rapid pain reduction compared to discectomy alone, though long-term functional outcomes may be similar 5
• Addition of anterior plating reduces pseudarthrosis risk and maintains lordosis but does not necessarily improve clinical outcomes for single-level disease 5
• For two-level disease, plating improves arm pain but not other clinical parameters 5
• Cervical arthroplasty is an alternative to fusion in selected patients for neck and arm pain control 5

Common Pitfalls to Avoid

• Do not order MRI routinely in the absence of red flags or failed conservative treatment, as findings often do not correlate with symptoms 1, 4
• Do not assume imaging findings are causative without clinical correlation—degenerative changes are ubiquitous in older adults 4
• Do not miss myelopathy by failing to test for hyperreflexia, Babinski sign, and gait disturbance in every patient 4
• Do not proceed to surgery without appropriate clinical correlation with imaging findings, as this leads to poor outcomes 3
• Be especially cautious with surgical indications in patients with anterolisthesis, as they have significantly higher rates of persistent pain even after surgery 8