What is the next step in management for mild anterolisthesis of C2 on C3, C3 on C4, and mild retrolisthesis of C5 on C6, with disc space narrowing and osteophyte formation at C4-C5 and C5-C6?

From the Guidelines

The next step in management for mild cervical spine anterolisthesis and retrolisthesis with degenerative changes should begin with conservative treatment. I recommend starting with physical therapy twice weekly for 6-8 weeks focusing on cervical stabilization exercises, postural correction, and gentle stretching. This should be combined with an anti-inflammatory medication such as naproxen 500mg twice daily or ibuprofen 600mg three times daily with food for 2-3 weeks. A muscle relaxant like cyclobenzaprine 5-10mg at bedtime may help with associated muscle spasms. Application of heat for 15-20 minutes several times daily can provide additional pain relief. If pain persists despite these measures, consider a cervical epidural steroid injection. These conservative approaches are recommended first because the described changes are mild and many patients improve without surgical intervention. The physical therapy strengthens supporting muscles while medications reduce inflammation around compressed nerve roots. Only if conservative management fails after 3-6 months, or if neurological symptoms worsen, should surgical options like anterior cervical discectomy and fusion be considered. Regular follow-up every 4-6 weeks during conservative treatment is important to monitor for any progression of symptoms or neurological changes, as suggested by guidelines for managing low back pain which can be applied to cervical spine conditions by analogy 1. Key considerations in the management plan include:

• Conducting a biopsychosocial assessment
• Developing a management plan with the patient
• Following an individualized stepped management approach as part of a multidisciplinary team (MDT) approach 1. Given the mild nature of the anterolisthesis and retrolisthesis, and the presence of degenerative changes, a conservative approach is preferred to minimize risks and optimize quality of life, in line with recommendations for managing similar conditions in the lumbar spine 1.

From the Research

Management of Mild Anterolisthesis and Retrolisthesis

The management of mild anterolisthesis on C2 on C3, C3 on C4, and mild retrolisthesis of C5 on C6, along with mild disc space narrowing at C4-C5 and C5-C6, and osteophyte formation at C4-C5, can be considered based on the following points:

• The presence of degenerative spondylolisthesis, including anterolisthesis and retrolisthesis, is a common radiographic finding in elderly patients with cervical spondylotic myelopathy (CSM) 2.
• The severity of spondylolisthesis can be classified into mild, moderate, and severe, with mild spondylolisthesis having a displacement of less than 2.0 mm 2.
• Patients with severe spondylolisthesis tend to have a higher incidence of degenerative spondylolisthesis at C3/4 or C4/5 and greater cervical mobility than those with mild spondylolisthesis 2.
• The association between osteophytes, end-plate sclerosis, and disc space narrowing is stronger in the lumbar spine, with osteophytes being more closely associated with end-plate sclerosis than with disc space narrowing 3.

Considerations for Treatment

Some key considerations for treatment include:

• The degree of displacement and the level of spondylolisthesis, as well as the presence of other degenerative changes such as disc space narrowing and osteophyte formation.
• The patient's symptoms and functional status, as well as any evidence of cord compression or spinal cord signal changes on MRI scans 2.
• The potential for conservative management, including physical therapy and pain management, versus surgical intervention, which may be considered for patients with severe spondylolisthesis or significant cord compression 2.