A retrolisthesis is a posterior displacement of one vertebral body with respect to an
adjacent vertebrae to a degree less than a luxation. Typically a vertebra is said to be in a
retrolisthesis position when it translates (slides) backward with respect to the vertebra below it. See classification below for more detail.

Retrolisthesis is the most common displacement component of subluxations encountered. Chiropractors take care of subluxations. Therefore retrolisthesis is one of the special interests of chiropractic practice and part of its everyday repertoire.  In the past this clinical pathology was also called a “retrospondylolisthesis”. (1)

A retrolisthesis is a displacement in the opposite direction to a spondylolisthesis (also called an anterolisthesis) - which is a forward displacement of one vertebral body on the vertebral body below it

Retrolistheses are most easily diagnosed on lateral (side on) x-ray views of the spine. Views where care has been taken to expose for a true lateral view without any rotation offer the best diagnostic quality. Retrolistheses are commonly under reported by radiologists due to medical x-rays used in the evaluation of the spine are usually performed with patients lying down. These are "non-stress" views and hence do not show the true extent of positional change while the patient is in a vertical, positionally stressed condition. A study I conducted also confirms the under reporting of retrolisthesis even where patients were x-rayed in a standing/stressed position.

Retrolisthesis is found mainly in the cervical spine and lumbar region but can also be often seen in the thoracic spine.

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 1 Classification
COMPLETE RETROLISTHESIS: 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 RETROLISTHESIS: The body of one vertebra is posterior to the body of the spinal segment above, but is anterior to the one below.
PARTIAL RETROLISTHESIS: The body of one vertebra is posterior to the body of the spinal
segment either above or below. (2) See examples

2 Grading
 

The preferred method of grading, is a measurement of the amount of displacement by measuring the bone displacement in millimetres. This is useful in determining the stability of the joint in question. See Joint stability below

Since the vertebral body in a retrolisthesis moves in a posterior direction, the grading used for
spondylolistheses is of little use. It is however possible at times to divide the anterior to
posterior dimension of the intervertebral foramina (IVF) into 4 equal units. A posterior
displacement of up to 25% of the IVF is considered as Grade 1, 25% to 50% as Grade 2, 50% to  75% as Grade 3, 75% to 100% occlusion of the IVF is Grade 4. The IVF is sometimes difficult to visualise. Therefore this method of evaluation is not universally useful.

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3 Evaluation & Measurement

This is done either by drawing lines using drawing instruments or by direct measurement using set squares:

There are always 2 vertebrae involved in measuring the magnitude of a retrolisthesis for translation (slippage). The lower segment is considered the position of stability. The upper segment rests on it. The upper segment is considered the segment of mobility and is the one being determined for retrolisthesis.

1) A line ① is drawn along the top of the vertebral body of the lower spinal segment.

See Photo.

2) Then at the top-back most portion of the lower vertebral body, draw line ② at 90 degrees to line ①, till it projects well into the body of the vertebra above.

3) Then draw another line ③ parallel to the line just drawn ② this time at the posterior most lower portion of the upper vertebral body.

4) The distance between the upright lines ② and ③ is measured. Any distance of 2mm or greater is a retrolisthesis. This measurement represents the degree of translation (slippage) of the upper of the two segments. See Photo.

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4 Significance
Retrolistheses are caused by injury and resulting instability of the connecting soft tissues
especially ligaments, discs, muscles, tendons and fascia. They may also involve muscles
through 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 (IVF). The IVF’s contents include spinal (sensory and motor) nerves, arteries, veins and lymphatic vessels which cater to the nutritional and waste removal needs of the spinal cord.

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 plate
osteophytosis, disc damage, disc narrowing, tearing failure and eventually results in disc bulging.

“A retrolisthesis hyper loads at least one disc and puts shearing forces on the
anterior longitudinal ligament, the annular rings, nucleus pulposis, 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. This is the aetiology of degenerative joint disease." (3)

[emphasis added]

Associated radiological findings include:

• Vacuum phenomenon (in the nucleus pulposis of the intervertebral disc below the retrolisthesis),

• Reduction of disc height with corresponding loss of the disc space,

• Marginal sclerosis (more dense due to stress) of the adjacent vertebral bodies,

• Osteophyte (spur) formation and

• Apophyseal (guiding) joint instability.

• With a retrolisthesis there is always a less than ideal positioning of spinal segments. (subluxation)

• There is also always a reduced anterior to posterior dimension of the spinal canal compared to the way it is supposed to be. This leads to nerve signal alteration.

• The greater the posterior displacement, the more significant it is for producing nerve root impingement and irritation, a dysfunctional spinal cord even to the point of a cauda equina compression syndrome if present in the lower lumbar spine.

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The tissues involved in retrolisthesis are:

• Ligaments - their function is to prevent excess movement between the bones they are attached to.

• Discs (space the vertebrae apart also prevents excess movement similar to ligaments.

• Fascia provides subliminal signalling to muscles, spreads injury impact loading.

• Muscle tone is required for correct postural and spinal balance. Muscle tone is a product of a properly functioning nervous system that is subluxation free. Sensible exercise within the limits of your injuries is important for the maintenance of proper tone.

• Spinal vertebrae - when they move far enough, especially backward, can cause direct pressure to nerves.

• Nerves need to function pressure free (irritation free) so they can control and co-ordinate all tissues, organs and systems of the body. The experience of life is made possible through nerve impulses. An irritated life is created through nerve irritation.  See prevention.

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5 Joint stability
Joint stability is easily evaluated by the use of flexion and extension lateral x-ray views of the spine.

A summary of part of the AMA Guidelines for Impairment Rating's Diagnosis Related Estimates (DRE) tables below (4) give a guide as to the severe implications of the joint instability excess spinal movement poses. If either translation or angular change is determined from flexion to extension to the degree shown in the table below, then Category IV instability is present.

Most retrolistheses however are found incidentally while looking for other things such as joint pathology or degeneration on neutral positioned lateral (side on) views of the spine using plain film x-rays.

If while viewing a neutrally positioned x-ray, one notices a translation of the order shown in the table below, even without the positional stress of flexion to extension movement, then instability must be present. Then we could suspect that 20% to 28% “whole person impairment” (depending on the region of the spine) is present at each level where this is found. In calculating the total whole person impairment it is NOT merely the case of adding the percentages. This calculation is best left to an impairment rating trained health care provider. Not all health care providers are trained in this area.

When there is translation present to the degree shown in the table below on standing (stressed by gravity) lateral view x-rays (non flexion/extension) views, this would indicate that the spinal joints at those levels are already in a "significantly stressed" state and would have a degree of soft tissue looseness at best and soft tissue tearing at worst, present otherwise a positional translation of this magnitude could not be present.





















 

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6 Symptoms
Retrolisthesis may lead to symptoms of greatly varying intensity and distribution. This is
because of the variable nature of the impact on nerve tissue and of the mechanical impact on
the spinal joints themselves.

Structural instability may be experienced as a local uneasiness through to a more far reaching
structural compensatory distortion involving the whole spine. If the joints are stuck in a
retrolisthesis configuration there may also be changes to range of motion.

Pain may be experienced as a result of irritation to the sensory nerve roots by bone depending
on the degree of displacement and the presence of any rotatory positioning of the individual
vertebra. The soft tissue of the disc is often caused to bulge in retrolistheses.
These cannot be determined by plain films, as the x-ray passes through the soft tissue.

A study by Giles et al, stated that:  

"Sixteen of the thirty patients (53%) had retrolisthesis of L5 on S1 ranging from 2–9
mm; these patients had either intervertebral disc bulging or protrusion on CT
examination ranging from 3–7 mm into the spinal canal. Fourteen patients (47%)
without retrolisthesis (control group) did not show any retrolisthesis and the CT did
not show any bulge/protrusion. On categorizing x-ray and CT pathology as being
present or not, the well positioned i.e.. true lateral plain x-ray film revealed a
sensitivity and specificity of 100% ([95% Confidence Interval. = [89%–100%]) for
bulge/protrusion in this preliminary study.” (5)

What this means is that in this study only people with a retrolisthesis had a bulging disc. No retrolisthesis - no disc bulge. This was present in those with a bulged disc 100% of the time.

The specificity medically means: The extent to which a particular diagnostic test is specific for a given condition. In this study the specificity was 100%. These 2 findings of this study makes it an extremely important though small study. It therefore points to the major value of plain film x-ray in diagnosis of the probability (greater than 50% chance) of a bulged disc by the presence of a retrolisthesis of greater than 2 mm of translation.

Both spinal cord or cauda equina compressions in the lumbar region are also possible with patients
experiencing pain, rigidity and neurological signs that may follow the pathway of those nerves
to cause symptoms at quite some distance from the location of the retrolisthesis.

Patients experiencing low back pain need to realise that there is often a spread of neurological dysfunction also that it is not restricted to the region of the low back.

Chronic pain and brain function

"Patients with CBP [Chronic Back Pain] showed 5-11% less neocortical grey matter volume than control subjects. The magnitude of this decrease is equivalent to the grey matter volume lost in 10-20 years of normal aging. The decreased volume was related to pain duration, indicating a 1.3 cm³ loss of grey matter for every year of chronic pain." (6) "Chronic back pain sufferers had significantly more directed diffusion in the three pain-processing regions of the brain. The organization of the cerebral microstructure is "much more complex and active in the areas of the brain involved in pain processing, emotion and the stress response," said co-author Gustav Schelling, M.D. (7)

So thinking ability is also affected.  There are major implications here for Fibromyalgia patients. (see Fibromyalgia & microcurrent) It is for this reason that the non-surgical interventions are necessary. It is imperative that nerves be enabled to function without irritations and if possible limit the damage that surgery inevitably makes incidentally in hopefully achieving its aims.

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Causes

Retrolisthesis may occur for 2 reasons:

1. Mechanical damage from physical trauma. (accidents, falls, repetitive use, poor posture etc)

2. Nutritional deficiencies of the components that make possible the building of strength and repair of discs and ligaments.

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7 Prevent Retrolisthesis
 

For the most part people are of the "if it ain't broke ... don't fix it" mentality, rather than working towards a "what do I need to do to keep my body working at its peak" thought process.

Retrolisthesis is the most common direction of misalignment or subluxations of the spine encountered. This makes retrolisthesis the speciality of chiropractors!

If you wish to prevent a subluxation developing into a significant (2mm or more) retrolisthesis, then it makes sense to prevent the wear and tear that would cause further damage to spinal joints (both soft tissues and bone), by the subluxation process. See how deterioration begins.

In short, this means having your spine checked for subluxations by qualified chiropractors who are the only health care professionals who by their university level training can find and adjust subluxations. If found, subluxations should be corrected using the gentlest means to get the adjustment done. With retrolisthesis prevention is better than attempts at a cure!

Work with your chiropractor and ask him/her what limits you should put on your activities to prevent excess strain on the soft tissues that hold the vertebrae in place. Generally, Pilates and Yoga tend to put too much pressure on the tissues involved because they are in an injured state. Also the attention of the trainer may not be sufficiently tuned to fine nuances of body position. many times the "core muscles" strength will be good, but doing exercise or sitting passively in a slumped and unsupported position will be enough to induce vertebral slippage. The tissues spoken of above, need to be repaired as soon as possible after injury. Your chiropractor will advise you specifically what to do to prevent the retrolisthesis from returning and what exercise you should or should not do.

Once a retrolisthesis measures 2mm or more, the non-surgical protocol below is needed to some extent as determined by your health care practitioner.

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8 Non-Surgical Protocol

None of the information listed below is to be taken as a directive to any particular person as a treatment. This information is provided as general information only, so that treatment options that you may not yet be aware of may be brought to the decision making process with the help of your suitably trained health practitioner.

1        Reposition
It is imperative that the abnormal location of the bone in retrolisthesis be corrected.
This is for 2 reasons:

A      To reduce abnormal stress on the soft tissues of the spine.    

        The longer the ligaments are stretched and the disc is in shear, the greater the likelihood of worsening displacement.
B      To reduce the irritation to nerves.

         Nerves may exhibit signs of abnormal function due to retrolisthesis, in the absence of pain. These may be abnormal reflexes, alteration of sensation on the skin, muscle spasm or cramping, weakness of muscles and atrophy, alteration of blood flow and temperature of the skin. A thorough physical examination will find these signs.

Chiropractic repositioning (adjustment) has been shown to be able to bring about a "significant reduction of retrolistheses displacement"(8) The soft tissue repair process can take longer than the pain control that most people with a retrolisthesis expect.

Position must be maintained during a repair process to achieve optimal results.
Because with a retrolisthesis, we are dealing with stretched soft tissues at best and torn at worst, it makes sense to use as little force as possible to bring about a positional correction.

To that end, I use chiropractic methods - Torque Release Technique and instrument
adjustments together with finger sized pressure as needed. Corrective forces are kept to a minimum while still having repositioning take place.

2        Robb Myofascial Release for soft tissue tone issues.

For muscle tone to function properly, it must be properly organised by the nervous system. If the tone is too great, we call that a spasm. It is an unwanted component of any spinal condition. Spasm can hold a bone in an unwanted and counter productive position and can prevent the optimally organised movement of the spine. Muscles in spasm can only pull in the direction of the muscle attachments (where the tendons attach to bones). Muscles at the back of the spine especially in the lumbar and cervical region will tend to pull the spinal bones in a front to backward direction. This is the same direction as the positioning of the segment in retrolisthesis. Too little tone and we lose position maintenance. This time we lose the lordosis of the cervical and lumbar spine. Here too we get into a situation where the spinal segments can also easily adopt a spinal retrolisthesis position. Myofascial release can be of benefit in restoring normal muscle tone and can add indirectly to stability.

Robb Myofascial Release is a method used to assist in resetting the abnormal neurological signal gain from habituated nerve signals both too and from the nerve rich fascia.

3        Nutrition
If the required nutrients for the repair of soft tissues that are responsible for maintaining spinal position are not present in the diet, then repair cannot and will not take place. The required nutrients, include:

• Copper is necessary for cross linking protein to add strength to membranes and ligaments. It is only needed in trace amounts. Excess copper can lead to toxicity and a depletion of zinc.

• Glucosamine,  1500mg per day is needed for cartilage repair. This is slow repair tissue and takes years to change supplements are the way to go.

• Manganese, Helps cross link protein. Therapeutic doses are only feasible as supplements

• Vitamin A, is available from butter, fast, oily fish, liver, cod liver oil, yellow an orange vegetables. Vitamin A is essential for tissue repair.

• Vitamin C is a major antioxidant and tissue builder. Increasing your intake is indicated if you bruise easily or have bleeding gums from brushing, Rats & goats make their own Vit C of the order of 4500mg per day when recalculated for a human adult. Makes you ponder the usefulness of the RDA's.

• Zinc is essential for the utilisation of Vit A. without zinc, Vit A may not be liberated from the liver even though it is plentiful. Zinc sources are oysters and shrimps. Both of these sources commonly contain toxins in them due to the environmental conditions where they are grown. A zinc taste test will determine your zinc status.

• Water is an essential component of spinal disc cartilage and is responsible in part for the height of the disc. The taller the disc the more taught the fibres of the disc and hence there will be less translational movement  of spinal segments.

Other nutrients like proteins and amino acids are also helpful for tissue repair and health.

 

During any repair process, it is important that the spinal bones be in the best position possible. So spinal adjustment of subluxations makes sense during the weeks and months that a repair takes.

See nutrition orders

 

4        Weight reduction
In the past, if you were over weight by 10% or more, then it was thought it would be of benefit to you to methodically go about reducing your weight. This is no longer the case. A study of twins and the spinal changes that happen when there is a weight difference, they found:

"despite extraordinary discordance between twin siblings in occupational and leisure-time physical loading [weight] conditions throughout adulthood, surprisingly little effect on disc degeneration was observed."(9) Note added

This is only study I know of that says weight doesn't matter. We need to watch this issue for other studies which say the same thing. Till then I would reduce weight sensibly making sure not to lose muscle mass along the way. There are other health benefits to maintaining a healthy body weight.

 

To ensure you are losing fat and not muscle mass, have a bio-impedance measurement done to determine a baseline measure before weight reductions is started and then re-check on this at no greater than 4 weekly intervals. That way you can modify your weight loss program if you need to without doing yourself harm.

5        Microcurrent therapy
Microcurrent therapy has been shown to be effective in pain control and stimulating tissue repair. (10)

I use microcurrent where steps 1, 2 and 3, listed above, on their own have not been able to show signs of repair. Microcurrent therapy as been shown to increase the energy component of cells (ATP) This is like giving the cells a battery boost. They are then more likely to be able to perform all of the tasks required of them including to repair.

See Microcurrent Therapy - the section on ligament repair will give you an idea of what is possible.

While microcurrent always boosts ATP, if there is a physical tear of the tissues and if the torn ends  are not connected, then a repair will take place but in a configuration of non-union. Diagnostic Ultrasound and MRI are at the edge of being able to show structures such as the ligaments of the spine, depending on the ligament's size and density.

It is imperative that the joints be in as good a position as possible during the time after the microcurrent sessions. For this reason, microcurrent is combined with chiropractic  adjustments which incorporate repositioning.

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9 Surgery
Surgery should only be attempted after all other avenues have been proven to be ineffective for you. The opinions of learned physicians and surgeons are just that ... opinions, unless they can verify with objective tests that you have a physical tear of tissues. If they can verify this, then surgery may be the best option. If they can't, then save yourself further trauma by trying the above non-surgical interventions first.

Spinal surgery is NOT without its risks. The prestigious medical journal Spine reported a significant

risk of death following spinal surgery. (11) 

Peter A Robb DC (PARDC)

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References
1         Hadley, Lee A. (MD), (1973) “Anatomicoroentgenographic Studies of the Spine”. 390.
2         Ruch, William J. (DC), (1997) “Atlas of Common Subluxations of the Human Spine and Pelvis”. 11.
3         Ruch, William J. (DC), (1997) “Atlas of Common Subluxations of the Human Spine and Pelvis”. 12
4         Cocchiarella L., Andersson G,. (1994) “American Medical Association Guides to the Evaluation of
           Permanent Impairment”, 4th edition, Tables 15- 3, 15-4, 15-5.
5         Giles, L.G.F.; Muller R.; and Winter G.J. (2006) “Lumbosacral disc bulge or protrusion suggested by
           lateral lumbosacral plain x-ray film – preliminary results.” Journal of Bone and Joint Surgery -
           British Volume, Vol 88-B, Issue SUPP_III, 450.
           see: http://proceedings.jbjs.org.uk/cgi/content/abstract/88-B/SUPP_III/450

6         http://www.jneurosci.org/cgi/content/abstract/24/46/10410 (2004)

7         http://fibroresearch.blogspot.com/2006/12/chronic-back-pain-linked-to-changes-in.html Posted Dec 2006; accessed Feb 2010

8         Plaugher G, Cremata EE, Phillips RB,  "A retrospective consecutive case analysis of pretreatment and comparative static

           radiological parameters following chiropractic adjustments" http://www.ncbi.nlm.nih.gov/pubmed/2273331

9         M. Battié et al. The Twin Spine Study: Contributions to a changing view of disc degeneration "The Spine Journal,

           Volume 9, Issue 1,  Pages 47-59 ; (2009)

10        "The Basis for Micro Current Electrical Therapy in Conventional Medical Practice"; JM Mercola and DL Kirsch PhD
11       "Mortality After Lumbar Fusion Surgery" Spine: 1 April 2009 - Volume 34 - Issue 7 - pp 740-747