In a 54-year-old woman with progressive lumbar disc herniation and disc fragmentation, does a mild retrolisthesis alter the recommended treatment approach?

Does Mild Retrolisthesis Alter Treatment for Progressive Lumbar Disc Herniation?

In a 54-year-old woman with progressive lumbar disc herniation and disc fragmentation, mild retrolisthesis does not fundamentally change the treatment approach—the primary indication for surgery remains the disc herniation itself, not the retrolisthesis. However, if surgical intervention is pursued, the presence of retrolisthesis may influence the decision to add fusion to decompression, particularly if instability is documented on dynamic imaging.

Primary Treatment Determination

• The disc herniation drives treatment decisions, not the retrolisthesis. Most patients with lumbar disc herniation experience relief with conservative management including physical therapy, anti-inflammatory medications, and time, with natural improvement typically occurring within the first 4 weeks 1.

• Retrolisthesis alone in patients with L5-S1 disc herniation does not correlate with worse baseline pain or physical function preoperatively 2. The symptomatic contribution of mild retrolisthesis is typically overshadowed by the disc herniation itself 2.

• Conservative treatment should include at least 6 weeks to 3 months of comprehensive management before considering surgical options, including formal physical therapy, neuroleptic medications (gabapentin or pregabalin), and anti-inflammatory therapy 1, 3.

When Retrolisthesis Becomes Clinically Relevant

Surgical Decision-Making Algorithm

If conservative management fails and surgery is indicated:

• First, obtain flexion-extension radiographs to assess for dynamic instability 1. Static imaging alone may not reveal instability that becomes evident with motion 1.

• If instability is documented (movement on flexion-extension films), fusion should be added to decompression. Class II medical evidence supports fusion following decompression in patients with lumbar stenosis and instability, with 96% reporting excellent/good results versus 44% with decompression alone 1.

• If no instability is present, decompression alone (discectomy) is appropriate 1. There is no convincing evidence to support routine fusion at the time of primary lumbar disc excision for patients without significant instability 3.

Intraoperative Considerations

• If extensive facetectomy (>50% facet removal) is required during decompression, fusion should be considered to prevent iatrogenic instability 1. This is a Grade B recommendation when extensive decompression might create instability 3.

• The presence of bilateral pars defects or spondylolisthesis (any grade) constitutes documented instability and represents a clear indication for fusion 4, 3.

Postoperative Outcomes with Retrolisthesis

• Patients with retrolisthesis who undergo L5-S1 discectomy may experience somewhat worse postoperative outcomes in terms of bodily pain and physical function over 4 years, though no significant differences were found in Oswestry Disability Index or Sciatica Bothersomeness Index 5.

• The contribution of pain related to retrolisthesis may become more evident after removal of the disc herniation 5. This suggests that while the disc herniation dominates the clinical picture initially, the retrolisthesis may contribute to residual symptoms postoperatively.

• However, retrolisthesis does not affect operative time, blood loss, length of stay, complications, or rate of additional spine surgeries 5.

Critical Pitfalls to Avoid

• Do not perform fusion based solely on the presence of mild retrolisthesis without documented instability. The definite increase in cost and complications associated with fusion are not justified in cases lacking clear instability criteria 3.

• Do not rely on static imaging alone. Dynamic flexion-extension radiographs are essential to assess true instability 1.

• Do not overlook the possibility that retrolisthesis-related pain may persist after successful discectomy 5. Patients should be counseled that while the radicular symptoms from disc herniation typically improve dramatically, some axial back pain related to the retrolisthesis may remain.

• Avoid performing extensive decompression without fusion when instability is present, as this can lead to progressive deformity and worse outcomes 1.

Treatment Algorithm Summary

1. Initial conservative management for 6 weeks to 3 months (physical therapy, medications, activity modification) 1, 3

2. If conservative treatment fails:

   • Obtain MRI to confirm disc herniation and assess for stenosis 1
   • Obtain flexion-extension radiographs to assess for instability 1

3. Surgical planning:

   • No instability + isolated disc herniation = Discectomy alone 1, 3
   • Instability present (movement on dynamic films) = Discectomy + fusion 1
   • Extensive decompression required (>50% facet removal) = Add fusion 1

4. Postoperative monitoring: Recognize that retrolisthesis may contribute to residual symptoms after successful disc herniation treatment 5