What is the management of trace anterolisthesis (anterior displacement of a vertebra) at L3-L4 and degenerative disc disease?

From the Guidelines

Management of trace anterolisthesis L3-L4 and degenerative disk disease should initially focus on conservative therapy, including pharmacologic and nonpharmacologic treatments, for at least 6 weeks before considering imaging or surgical interventions. This approach is supported by the American College of Radiology's 2021 update on low back pain, which emphasizes the importance of conservative therapy as the first-line treatment for chronic low back pain 1.

Initial Treatment

Initial treatment should include pain management with NSAIDs, such as ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily), combined with acetaminophen (500-1000mg every 6 hours as needed) for breakthrough pain. Physical therapy is essential and should include core strengthening exercises, lumbar stabilization techniques, and stretching programs performed 3-5 times weekly for at least 6-8 weeks 1.

Imaging and Further Interventions

Imaging, such as MRI of the lumbar spine, should only be considered if the patient has failed 6 weeks of conservative therapy and is believed to be a candidate for surgery or intervention, or if diagnostic uncertainty remains 1. MRI has excellent soft-tissue contrast and accurately depicts lumbar pathology, including disc degeneration, as well as the thecal sac and neural structures.

Surgical Options

Surgical options, such as decompression with or without fusion, should only be considered for patients with progressive neurological deficits, severe uncontrolled pain, or significant functional limitations despite comprehensive conservative management 1. Upright radiographs, including flexion and extension radiographs, can provide useful functional information about axial loading and segmental motion, which is important in the surgical management of spondylolisthesis 1.

Key Considerations

• Conservative therapy should be the initial approach for at least 6 weeks.
• Imaging should only be considered if conservative therapy fails or if there are red flags.
• Surgical options should be reserved for patients with severe symptoms or significant functional limitations despite comprehensive conservative management.
• Weight management and activity modification are crucial components of conservative therapy.
• A stepwise approach, addressing both the mechanical instability of anterolisthesis and the inflammatory component of degenerative disk disease, is essential to minimize risks associated with more invasive interventions 1.

From the Research

Management of Trace Anterolisthesis L3 L4 and Degenerative Disk Disease

• The management of trace anterolisthesis L3 L4 and degenerative disk disease typically involves conservative treatment options, including the use of analgesics and NSAIDs to control pain, epidural steroid injections, and physical methods such as bracing and flexion strengthening exercises 2.
• Nonoperative treatment should be the initial course of action in most cases of degenerative spondylolisthesis, with or without neurologic symptoms 2, 3.
• A trial of conservative therapy may be considered for patients with low-grade spondylolisthesis presenting with radiculopathy and/or pseudoclaudication, and may include physical therapy, epidural steroid injection, and pain medications 4.
• If conservative management fails, surgical options may be considered, including decompression alone or decompression and fusion 4, 5.
• The diagnosis of spondylolisthesis should be determined by an upright x-ray, and physical therapy is generally considered appropriate in most scenarios, especially in patients with back pain and no neurological deficits 6.
• Epidural steroid injections are most appropriate in patients with radiculopathy, and surgery is generally more appropriate for patients with neurological deficits, higher disability scores, and dynamic spondylolisthesis 6.

Treatment Options

• Conservative treatment options:
  • Analgesics and NSAIDs to control pain
  • Epidural steroid injections
  • Physical methods such as bracing and flexion strengthening exercises
  • Physical therapy
• Surgical treatment options:
  • Decompression alone
  • Decompression and fusion
  • Posterior fusion with or without interbody fusion
  • Stand-alone interbody fusion
  • Interspinous spacers

Appropriate Use Criteria

• The North American Spine Society Appropriate Use Criteria provides comprehensive evidence-based recommendations for evaluation and treatment of degenerative spondylolisthesis 6.
• The criteria consider various clinical scenarios, including bone grafting, imaging, mechanical instability, radiculopathy with or without neurological deficits, obesity, and yellow flags consisting of psychosocial and medical comorbidities 6.