|Year : 2015 | Volume
| Issue : 2 | Page : 111-116
Retrolisthesis: An update
Sahar Zaidi, Shibli Nuhmani, Jyoti Jalwan
Department of Rehabilitation Sciences, Jamia Hamdard, New Delhi, India
|Date of Web Publication||6-May-2015|
Department of Rehabilitation Sciences, Hamdard Institute of Medical Sciences, Hamdard University, New Delhi
Retrolisthesis is the posterior displacement of one vertebral body with respect to the adjacent vertebrae, to a degree less than a dislocation. It is associated with increased by a degree, and thus impaired function of the spine. It is correlated with a reduction in lumbar lordosis, end plate inclination and segmental height. Retrolisthesis hyper loads at least one disc and puts shearing forces of the anterior longitudinal ligament, the annular rings, nucleus pulposus and cartilage end plate ligament. There is a paucity of literature on the effective treatment of retrolisthesis. This article presents an overview of the etiology and symptoms of retrolisthesis and highlights the conservative management for the same. This will assist the health care practitioners who are treating this condition.
النزوح الفقري (Retrolisthesis)
النزوح الفقري هو نزوح واحدة من فقرات العمود الفقري عن الفقرات المجاورة إلى درجة أقل من الخلع و كلما زادت درجة النزوح أدى ذلك إلى اختلال في وظائف النخاع الشوكيّ ويرتبط ذلك بانخفاض في القعس القطنيّ وميل في الصفيحة النهائية والارتفاع القطعي. هذا النزوح يزيد الحمل على قرص واحد على الأقل ويؤثر علي قوة الرباط الأمامي والرباط الخلفي ، والنواة اللبية والغضروف و رباط الصفيحة النهائية. هنالك ندرة في أدبيات العلاج الفعال لمثل هذه الحالات من النزوح الفقري. هذه المقالة تقدم ملامحا عامة عن الحالة وأعراضها، كما تسلط الضوء على طرق الوقائية وفي الوقت نفسه تساعد ممارسي الرعاية الصحية ذوى الاهتمام على علاج هذه الحالة
Keywords: Degenerative changes, myofascial release, sciatica
|How to cite this article:|
Zaidi S, Nuhmani S, Jalwan J. Retrolisthesis: An update. Saudi J Sports Med 2015;15:111-6
| Introduction|| |
Retrolisthesis can be classified as complete; stair stepped and partial depending upon the position of the vertebral body with respect to the position of the vertebral body of the spinal segment above and below. It is called complete when the body of one vertebra is posterior to both the vertebral body of the segment of the spine above as well as the segment below, stair stepped when the body of one vertebra is posterior to the body of the spinal segment above, but is anterior to the one below and partial retrolisthesis when the body of one vertebra is posterior to the body of the spinal segment either above or below.  Retrolisthesis can occur due to the posterior orientation of the facet planes which draws the vertebra above posteriorly as the disc height decreases. Anterior to posterior dimension of the intervertebral foramina can be divided into four equal units. A posterior displacement of up to ¼ of the inter vertebral foramen is graded as Grade 1, ¼¼ to ¾ as Grade 2, ¾¾ to ½ as Grade 3, ½½ to total occlusion of the inter vertebral foramen as Grade 4.
Exercises are the mainstay of treating retrolisthesis conservatively and strengthening the abdominal muscles; deep abdominal oblique and lumbar multifidus should be emphasized upon.  It can be conservatively treated by improving posture during performance of all activities of daily living, weight reduction, dietary changes, nutritional supplementation and microcurrent therapy to relieve pain and help repair tissue assisted by a brace or a corset. The brace is worn until the abdominal muscles are strengthened by exercise, and the person can maintain his posture during activities of daily living. Transverses abdominis muscle is most important in spinal stability as they stabilize the spine and become activated before any upper extremity movement occurs. Strengthening should be accompanied with proper techniques of lifting and bending.  According to a study by Shen et al.  the overall incidence of retrolisthesis at L5-S1 was 23.2%. Retrolisthesis combined with posterior degenerative changes, degenerative disc disease, or vertebral endplate changes had incidences of 4.8%, 16%, and 4.8%, respectively. The prevalence of retrolisthesis did not vary by sex, age, race, smoking status, or education level when compared with individuals with normal sagittal alignment. The overall lordosis, end plate inclination and segmental height were found to be reduced in patients with retrolisthesis. However, orientation of facet joints was not affected. , Vertebral displacement associated with disc degeneration is most commonly in a posterior direction (retrolisthesis, retrosubluxation, retroposition). Patient rotation and lateral flexion can simulate retrolisthesis.
| Etiology|| |
In children, the most common cause is a birth defect which occurs most commonly between the fifth vertebra and the sacrum. In adults, it usually occurs between the 4 th and 5 th vertebra due to arthritis or any other degenerative disease. Other causes may include stress fractures and traumatic fractures, infections of blood or bone, bone disease, nutritional deficiencies of the components that are responsible for building of strength and repair of discs and ligaments. Retrolisthesis are mainly caused by injury and resulting the instability of the connecting soft tissues, especially ligaments, discs, muscles, tendons and fascia. They may also involve muscles through a spasm as a result of nerve malfunction due to a change in pressure caused by the posterior displacement of the vertebra encroaching on the contents of the space where the spinal nerves exit from the bones of the spinal column. Degenerative spinal changes are often seen at the levels where a retrolisthesis is found. These changes are more pronounced as time progresses after injury and are evidenced by end plateosteophytosis, disc damage, disc narrowing, tearing failure and eventually results in disc bulging. A retrolisthesis hyper load at least one disc and puts shearing forces on the anterior longitudinal ligament, the annular rings, nucleus pulposus, cartilage end plates and capsular ligaments. The bulging, twisting and straining tissues attached to the endplates pull, push and stretch it. It is worsened with time, gradually becoming irreversible.
| Anatomy|| |
Morgan and King found that the retrolisthesis results from congenital laxity or gradual stretching of the ligaments at the lateral articulations. During spinal extension, the lateral facets of the upper vertebra have a tendency to move backwards partly owing to the force of gravity and partly because the surface of the lamina slopes downwards and backwards. Therefore, when the end of the articular surface is reached by the point of the facet, it is carried backward until the stretched ligament becomes taut.  By bending his trunk forwards, the patient approximates the surfaces of the facet joints once more. Such instability at these lateral joints leads to attrition of the disc. At the upper lumbar levels; this is usually a benign phenomenon, but particularly at the fourth level, may give rise to disc symptoms-backache, lumbago and sciatica.
| Symptoms|| |
Retrolisthesis has an impact of a variable nature on nerve tissue and mechanical impact on the spinal joints themselves. Structural instability varies from the local uneasiness to structural compensatory distortion involving the whole spine. With joint involvement, there may be changes in posture and range of motion, which depend upon the degree of vertebral displacement. The soft tissue of the disc is often caused to bulge in retrolisthesis.  The ability to move freely may also be compromised to some extent. Majority of retropositions are asymptomatic, though such a subluxation tends to displace nerve roots cranially and predispose to lateral entrapment from the superior facet from the segment below. 
It occurs as a result of irritation to the sensory nerve roots by bone and depends on the degree of displacement and rotation of the individual vertebrae.
Constant pressure on the nerve root that exits the spine at that particular level leads to tingling, numbness or pain in the hip, buttock, thigh or leg, while cervical retrolisthesis could affect the neck, shoulder or arm. Giles et al.  associated retrolisthesis with a bulging disc. No retrolisthesis - no disc bulge.
| Prevention|| |
Prevents the wear and tear that would cause further damage to spinal joints by the subluxation process. Correct any subluxations using the gentlest means to get the adjustment done. Prevent excess strain on the soft tissues that hold the vertebrae in place. Strengthen the core muscles. The tissues need to be repaired as soon as possible after injury. With a retrolisthesis of 2 mm or more, the surgical protocol will be required, therefore, prevention is better than attempts at a cure.
| Treatment|| |
The treatment for retrolisthesis depends upon the severity of injury. There are surgical as well as nonsurgical protocols, but physical therapy treatment provides maximum relief.
| Nonsurgical treatment|| |
The abnormal positioning of the vertebra in retrolisthesis is corrected to reduce abnormal stress on the soft tissues of the spine and to reduce the irritation to nerves.
Robb myofascial release
Myofascial release restores the normal muscle tone and indirectly adds to stability. Myofascial release improves range of motion by relaxing contracted muscles improving venous and lymphatic circulation and stimulating the stretch reflex of muscles.
Vitamin and mineral supplements are encouraged to help repair soft tissue damage and maintain the spinal position. Copper, glucosamine, manganese, Vitamin C, zinc, and water is suggested. Other nutrients like proteins and amino acids are also helpful for tissue repair and health.
Microcurrent therapy can reduce swelling and inflammation, mask acute pain, release muscle trigger points, control pain, stimulate tissue repair and improve soft tissue regeneration.
Water therapy exercise programs provide relief of low back pain or neck pain, serve to condition and strengthen muscles to help avoid future recurrences of back pain and is especially helpful in cases where a land-based exercise program is not possible due to the intensity of pain, decreased bone density, disability or other factors.
One must quit smoking as it can cause further joint deterioration and damage. Weight reduction is recommended in order to take pressure off the vertebra.
| Physical therapy treatment|| |
The mobility exercises are the main contributors to the mechanical efficiency of the spine and the whole body. Apophyseal joints of the spine require mobility or movement to facilitate nutrition and to prevent degeneration of the articular cartilage. 
Flexibility aims at improving disc nutrition. Gentle and progressive heat and controlled rapid stretching improves flexibility. Elongation exercise must be initiated, but biomechanical properties of collagen fibers must be kept in mind. Flexibility exercises must include rotation as well as sagittal motion. 
Strengthen deep abdominal muscles, especially the transversus abdominis and quadratus lumborum.
Effects of exercise
They increase strength of bones, ligaments and muscles, improve nutrition to joint cartilage, including intervertebral disc, enhance oxidizing capacity of skeletal muscles, improve neuro-motor control and coordination, promotes a feeling of well-being as there is an increase in the alpha wave activity, producing central and peripheral relaxation and decrease in the muscle tension and exercise also increases the level of endorphine in the cerebrospinal fluid and blood, which is found to be reduced in patients with back pain. Endorphine has been proved to have a significant pain modifying effect, reduce the symptoms of depression and anxiety. 
Therapeutic life style changes
Patient education about the condition and the list of precautions play a significant role. Relative changes in posture and activities affect intradiscal pressure. Sitting with the hips, and knee flexed or leaning forward should be avoided for acute disc lesions, lumbar spine should be supported with the trunk inclined 120° as it provides the lowest load to the disk. Correct lifting and bending techniques are taught. Sitting for a bowel movement may cause a marked increase in intradiscal pressure because of valsalva maneuver. The patient is taught to sit leaning back, with a wide base of support. Use of raised toilet seat is advisable.
The optimal amount of bed rest during the acute phase is beneficial. During the first 2 days when symptoms are highly irritable, bed rest is needed to promote early healing, but it should be interspersed with short intervals of standing, walking and appropriately controlled movement. Resting on a firm bed to allow fibrin to form is helpful. It promotes lumbar extension and stimulates fluid mechanics to help reduce swelling in the discs or connective tissue.
| ADHESIVE STRAPPING/SPINAL SUPPORTS|| |
Role of lumbar spinal support in low back pain
It enhances the natural splintage effect as it maintains the physiological lumbar curve and provides partial immobilization thus protects the lumbar spine from stresses of movements. Immobilization helps in reducing pain due to muscle spasms.  Restriction of movement allows early safe mobility, which is preferred to rest and immobilization. It allows transmission of forces of gravity and weight facilitating early ambulation. It provides support and reassurance to the patient, especially beneficial in acute lumbago or disc lesions. It facilitates the natural splintage provided by abdominal and spinal muscles. It uplifts and supports the abdomen, thereby unloading the effects of gravity on the discs.
modalities such as heat or ice packs, transcutaneous electrical nerve stimulation (TENS) and ultrasound have been found to be beneficial. 
Hot pack 10 min, moderate heating. According to Kramer  therapeutic effect, is achieved by gating of pain transmission by activation of cutaneous chemoreceptors and results in improved healing and decrease in muscle spasm. It is also effective in increasing joint range of motion and decrease joint stiffness by increasing soft tissue extensibility reported in a study by Lehmann et al. 
It promotes vascular dilation, which alters metabolic activity hemodynamic action, neural response, and modification of collagen tissue. Heating an area over a peripheral nerve induces analgesia distal to the application site, in the dermatomal area. Metabolic rate increases to 3-fold with every 10°C rise. Superficial heat causes a reflex postganlionic sympathetic nerve activity to the smooth muscles of the blood vessels, thereby supplying more blood to the muscles.  Heat is indicated after a brief period of cryotherapy to bring blood supply to the area and facilitate healing. The duration of the application is usually 20 min several times a day for 3 to 5 days. It has a specific value when it is used to precede the exercise; this is its major benefit. Again, this modality can be applied at home before or after an exercise program or even without exercise as the pain demands. Moist heat in the form of hydrocollator packs reduces pain and spasm in the acute phase.
Transcutaneous electrical nerve stimulation
A TENS unit uses electrical stimulation to modulate the sensation of lower back pain by overriding the painful signals that are sent to the brain.  Trans-cutaneous electrical stimulation over the trigger points of acupuncture points have been reported to be effective in both acute as well as chronic conditions. , It reduces the perceived pain by elevating endogenous opiate levels in the brain and spinal cord and continuous stimulation of cutaneous afferents blocks pain in the substantial gelatinosa of the spinal cord. Frequency of 2-4 Hz, output intensity of 50 MA, pulse rate of 2 pulses/s and pulse width between 30 and 60 min has been reported to be an effective mode of application in chronic, as well as acute conditions.
| Retrolisthesis exercises|| |
Specific exercise protocols
Walking as an exercise prescription is probably the simplest, least stressful, and the most beneficial therapeutic exercise for the low back. In proper walking, there is contralateral swing of the arms, which causes physiologic rotation of the trunk at each step. As physiologic rotation of each functional unit occurs, the collagen fibers of that layer and, therefore, of that angulation are extended, which strengthens them. 
A strong core can take the pressure off the spine. Strengthening the gluteal and abdominal muscles reduces pain in the lower back and buttocks. Pelvic tilts can improve strength in your abs and back without strain.
Effects of extension exercises: 
Extension exercises are of two types:
- Extension exercises promote normal physiologic lumbar curve of the spine allowing it to withstand axial compression force, thus facilitating lifting loads
- They improve the motor recruitment, strength and endurance of the extensor muscles of spine and hip
- Extensors are the main muscle groups in postural holding and in the eccentric control of trunk flexion
- They improve the mobility of the spine
- They improve tone in the extensor muscles which is often reduced because of the maximum natural flexion attitude of the human body.
- Extension to neutral. It involves concentric contraction of the back extensors from flexion of 40° to 45° of the trunk. The advantage of this exercise is that it involves eccentric contractions of the extensors, when the trunk returns to its initial position of 40-45° of flexion
- Hypertension exercise: In prone, the patient extends the spine beyond the neutral positions up to 15-30° of hypertension.
Spinal exercises are necessary to rehabilitate the spine and help alleviate back pain. Active exercises should be done in a controlled, gradual and progressive manner. McKenzie protocol is considered beneficial in the acute stage.
Movement distributes nutrients into the disc space and soft tissues in the spine to keep the discs, muscles, ligaments and joints healthy. These exercises also help to recede the bulge of the disc.
The most important core exercise is the drawing in maneuver which helps to re train the deep core muscles. 
Pelvic tilts offer a low-impact lower back strengthening exercise that is performed while lying down. This exercise helps loosen stiff joints and relieve pain. The exercise also tightens and strengthens the lower muscles of the abdominal wall and pelvis. 
Lower back rolls
Lower back rolls help provide a stretch for the lower back, but it is not performed if retrolisthesis has caused moderate to a severe placement of the lower vertebrae.
Ergonomics has held a prominent place in proper body mechanics. Ergonomics is defined as, the science concerned with how to fit the job to man's anatomical, physiologic and psychologic characteristics in a way that will enhance human efficiency and well-being.
Posture and ergonomic advice
The patient needs to be educated about proper posture and ergonomics so as to avoid recurrence of the condition and to promote functional independence in the future without unnecessary burden on the structure of the back.
Sitting is a static posture that can cause increased stress in the back, neck, arms and legs and can add a tremendous amount of pressure to the back muscles and spinal discs. In addition, sitting in a slouched-over or slouched-down position in a chair can overstretch the spinal ligaments and strain the spinal disc. 
- Lower back support: One's back should be pressed against the back of the chair, and there should be a cushion that causes the lower back to arch slightly so that one doesn't slump forward. This support is essential to minimize the load on the back. Never slump or slouch in the chair, as that places extra stress on the spine and lumbar discs
- Back rest: It provides stability to the sitter. A vertical backrest provides no support because it prevents the sitter from leaning backwards. The tendency is for the sitter to slide his buttocks forward to obtain support. Sitting with a back rest inclination of 120° provides the lowest load to the disc. In working situation, where the sitter has to lean forward over the desk, it is periodically useful for him to lean backwards
- Firmness of seat: A soft surface where the sitter sinks into a concavity causes the hip to rotate internally exposing the sciatic nerve to pressure laterally. Usually a firm rather than hard support is more comfortable
- Driving posture: Simple alterations to the existing seats produce a marked effect on the comfort
- Back rest angle: An angle >90° which gives a lower level of intradiscal pressure is often preferred, but the patient should be instructed to rest back against the backrest, provided the visual demands are met
- Head rest: The head rest should support the mid line of the head to keep it upright. Tilt the headrest forward if possible to make sure that the head to head rest distance is not >4 inches
- Sleeping posture with mattresses and pillow
- A relatively firm mattress is generally best for proper back support, although individual preference is very important
- Sleeping on the side or back is usually more comfortable for the back than sleeping on the stomach
- Use pillow to provide proper support and alignment for the head and shoulders
- Consider putting a rolled-up towel under the neck and a pillow under the knees to better support the spine
- If sleeping on a side, relatively flat pillow placed between the legs will keep the spine aligned and straight
- Instruct the patient that while getting up from the bed first come to side lying position, then move the legs down and then raise up with the support of his hand on the bed on the side to which he is lying.
The correct lifting techniques should follow the following rules:
- Keep the chest forward: Always be sure to bend at the hips and not the lower back. Most people believe bending their knees will ensure a safe lift, but this form can still lead to a back injury. The most important tip is to bend the hips and push the chest out, pointing forward. Furthermore, one should never twist. Bending the knees alone will still allow a person to curve the back and risk and injury, but keeping the chest pointing forward will guarantee a straight back. The back muscles will then be used most effectively for maintaining good posture
- Lead with the hips and not the shoulders. Twisting is another dangerous mistake that can lead to the back injury. The shoulder should be kept in line with the hips to avoid the movement. For changing direction, move the hips first so the shoulders will move in unison. When moving the shoulders first, the hips tend to lag behind creating the dangerous twisting that can cause back injury
- Keep the weight close to the body. The further an object is kept from one's center of gravity; the more force is needed to hold that object. This extra force generated will also run through the injury.
| Surgical treatment|| |
Surgery can be a last resort treatment for those suffering from retrolisthesis. The surgical treatment aims to reduce pain, prevent further slip, stabilize unstable segment, reverse neurologic deficit and restore posture and gait.
| Conclusion|| |
Patients suffering from retrolisthesis who were given an exercise protocol, which included stretching and strengthening after application of electrotherapeutic modalities for pain relief and were instructed with the required precautions had improved visual analog scores and Oswestry disability scores and improved dynamic abdominal endurance. Therefore, conservative treatment plays an instrumental role in the management of retrolisthesis.
| Acknowledgments|| |
We express our sincere thanks to Dr. Zoheb A Siddiqui and Dr. Nayeem U Zia for helping in the review process.
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