Retrolisthesis: Definition and First-Line Treatment
Retrolisthesis is the posterior (backward) displacement of one vertebral body relative to the vertebra below it, most commonly occurring in the lumbar spine at L3-L4 or L4-L5 levels, and first-line treatment consists of conservative management with physical therapy, exercise programs to maintain activity, and non-narcotic analgesics for at least 6 weeks before considering imaging or advanced interventions. 1, 2
What is Retrolisthesis?
Retrolisthesis represents posterior vertebral translation, typically defined as backward subluxation of 8% or more of one vertebral body on the adjacent lower vertebra. 3 This condition differs fundamentally from the more commonly discussed anterolisthesis (forward slippage):
Location patterns: Retrolisthesis predominantly manifests at L3, though the specific level can be influenced by the presence of simultaneous anterolisthesis elsewhere in the spine. 2
Compensatory mechanism: Retrolisthesis functions as a compensatory mechanism to move the body's gravity axis posteriorly in response to sagittal imbalance, particularly in patients with low pelvic incidence and insufficient intraspinal compensation. 2, 4
Associated features: Patients with retrolisthesis demonstrate lower pelvic incidence, pelvic tilt, and lumbar lordosis compared to those with anterolisthesis, along with increased thoracolumbar kyphosis. 4
Prevalence: In patients with L5-S1 disc herniation requiring surgery, retrolisthesis occurs in approximately 23% of cases. 3
First-Line Treatment Approach
Conservative Management (Initial 6 Weeks)
The ACR guidelines explicitly state that subacute to chronic low back pain without red flags is a self-limiting condition responsive to medical management and physical therapy in most patients, and routine imaging provides no clinical benefit and can lead to increased healthcare utilization. 1
Initial conservative therapy should include:
Pharmacologic management: Non-narcotic pain medications as first-line agents, with narcotic medications reserved for refractory cases. 5
Physical therapy: Exercise programs emphasizing remaining active rather than bed rest. 1
Activity modification: Ergonomics coaching and postural adjustments to reduce mechanical stress. 6
When to Consider Imaging
Imaging should only be pursued after 6 weeks of failed conservative therapy in patients who are candidates for surgery or intervention, or when diagnostic uncertainty remains. 1
If imaging becomes necessary:
MRI lumbar spine without contrast is the initial imaging modality of choice, providing excellent soft-tissue contrast and accurate depiction of disc degeneration, thecal sac, and neural structures. 1
Flexion-extension radiographs are essential to identify segmental motion, which is important in surgical management of spondylolisthesis (including retrolisthesis). 1
CT myelography serves as an alternative for patients with MRI-incompatible devices or significant metallic hardware artifact. 1
Advanced Conservative Options (After Initial Failure)
For patients with persistent symptoms beyond 6 weeks who are not yet surgical candidates:
Epidural steroid injections (interlaminar or transforaminal) may provide short-term relief (less than 2 weeks) in chronic low back pain, though evidence for long-term benefit is limited to Level III data. 7
Facet joint injections may be considered if facet-mediated pain is suspected, though double-block technique is most reliable for diagnosis. 7
Multimodal chiropractic care including spinal manipulation, axial distraction, and isometric stretching showed benefit in one case report, though this represents lower-level evidence. 6
Important Clinical Considerations
Retrolisthesis Does Not Predict Worse Outcomes
The presence of retrolisthesis alone is not associated with increased preoperative low back pain, worse physical function, or increased incidence of degenerative disc disease compared to patients without retrolisthesis. 3 This finding suggests that when retrolisthesis coexists with disc herniation, the disc pathology overshadows any contribution from the vertebral displacement itself.
Disk Degeneration Relationship
Retrolisthesis is associated with relatively preserved disc integrity, with average Pfirrmann scores of 2.11 at affected levels, indicating disks are not severely degenerated. 4 This contrasts with the severe disc degeneration typically seen in anterolisthesis.
Red Flags Requiring Immediate Imaging
While not explicitly detailed in the provided evidence for retrolisthesis specifically, standard spine care principles dictate immediate imaging for: cauda equina syndrome symptoms, progressive neurological deficits, suspected infection, malignancy, or trauma. 1
Surgical Considerations
Surgery is not routinely recommended in first remission for degenerative lumbar conditions but may be indicated for higher-risk subsets or those with suboptimal responses to initial therapy after appropriate conservative management. 7, 5 Surgical decision-making should incorporate assessment of segmental motion on dynamic radiographs. 1