Patients with suspected spondylolisthesis require detailed clinical and radiographic examinations. This includes taking a detailed history, performing a thorough physical examination, and obtaining appropriate imaging studies to establish the severity of disease. The comprehensive evaluation of the spondylolisthesis patient is reviewed in other chapters. However, once the evaluation is complete, the clinical and radiographic examinations must correlate with the patient’s complaints and guide possible treatment options.

While no randomized studies have been reported to date that delineate a non-operative treatment algorithm, a multi-dimensional approach is advocated. All patients should be educated about the benefits of practicing healthy back care with proper lifting and bending techniques and understanding ergonomics, along with avoiding prolonged periods of sitting and driving. Smoking cessation, along with weight loss to obtain an ideal body weight should be emphasized as risk factors that the patient can control in an attempt to reduce or eliminate their back pain. Additionally, activity modification can reduce environmental pain generators, along with various physical therapy (PT) modalities with attention to core strengthening, flexion and extension exercises, aerobic conditioning for weight loss, and the occasional utilization of bracing.

Non-narcotic medications including the use of non-steroidal anti-inflammatory drugs (NSAIDs) should also be part of the initial conservative treatment plan. Steroid injections including inter-laminar, transforaminal, pars inter-articularis, as well as facet injections can also be therapeutic and offer diagnostic value. Additionally, chiropractic spinal manipulation and acupuncture are alternative treatment modalities. When patients do not improve with these non-operative treatment options, surgery may be indicated.

Conservative therapy must be specific to the disease being treated. As part of most PT programs, low-impact aerobic activity is encouraged for weight loss. The use of a stationary bike is promoted because the flexed posture of the lumbar spine, and leaning forward theoretically opens the central canal and neural foramen, potentially alleviating neurologic symptoms in patients with stenosis. Exercises focused upon stability of the trunk should be implemented when seeking to treat spondylolisthesis through conservative modalities. Flexion-based PT exercise regimens appear to be superior to extension-based programs in achieving symptomatic relief.

Flexion exercises have been shown to yield favorable results in the few randomized studies published. Sinaki et al. reported on 48 patients with symptomatic low back pain secondary to spondylolisthesis who were treated conservatively and followed for 3 years after initial examination to compare the outcomes of two exercise programs [2]. The patients were divided into two groups: those doing flexion abdominal exercises and those doing extension back strengthening exercises. All patients received instructions on posture, lifting techniques, and the use of heat for relief of symptoms. After 3 months, only 27 % of patients who were instructed to perform flexion exercises had moderate or severe pain, and only 32 % were unable to work or had limited their work. Of the patients who were instructed in extension exercises, 67 % had moderate or severe pain, and 61 % were unable to work or had limited their work. At 3-year follow-up, only 19 % of the flexion group had moderate or severe pain and 24 % were unable to work or had limited their work. The respective figures for the extension group were 67 and 61 %. The overall recovery rate after 3 months was 58 % for the flexion group and 6 % for the extension group. At 3 years these figures improved to 62 % for the flexion group and dropped to 0 % for the extension group. Based on these findings, the authors suggested that if a conservative treatment program is prescribed, flexion or isometric back strengthening exercises should be considered.

Gramse et al. reported on 47 patients with symptomatic back pain secondary to spondylolisthesis who were not surgical candidates and treated with a physical therapy program [3]. Twenty-eight patients were treated with flexion exercises of the lumbar spine. Nineteen patients were treated with extension-type exercises, in addition to flexion exercises. At follow-up, 7 of the 28 patients (25 %) in the flexion exercise group rated their pain as moderate to severe, whereas 13 (68 %) of 19 in the extension group rated their pain as moderate to severe. In the flexion group, 23 patients (82 %) reported less pain, and 5 (18 %) rated their pain as unchanged or worse, whereas patients in the extension group, 7 (37 %) rated their pain as less, and 12 (63 %) as unchanged or worse. In addition to having less pain, the flexion exercise group did not modify their work and leisure activities as much, had less dependence on lumbar bracing, and a greater chance of recovery.

O’Sullivan performed a randomized, controlled trial, using a test–retest design by mailing questionnaires at 3, 6, and 30-months follow-up to determine the efficacy of a specific exercise intervention in the treatment of patients with chronic low back pain and the diagnosis of spondylolysis or spondylolisthesis [4]. Forty-four patients with this condition were assigned randomly to 2 treatment groups. The study group underwent a 10-week exercise treatment program involving the specific training of the deep abdominal muscles, with co-activation of the lumbar multifidus proximal to the pars defects. The control group underwent treatment as directed by their treating practitioner. After intervention, the study group who participated in the specific exercise treatment program showed a statistically significant reduction in pain intensity and functional disability levels, which was maintained at the 30-month follow-up. The control group showed no significant change in these parameters at no time point throughout the study. The authors concluded that a “specific exercise” treatment approach appears more effective than other commonly prescribed conservative treatment programs in patients with chronically symptomatic spondylolysis or spondylolisthesis.

Predicting treatment response to physical therapy can be difficult when implementing physical therapy exercises. Hicks et al. prospectively sought to determine predictors for successful treatment of low back pain through stabilization exercises in patients with lumbar segmental instability [5]. They were able to report on a total of 54 patients over a 1-year period. Patients underwent an 8-week biweekly program with additional home exercises verified via self-logs. The program was designed to specifically assess core stabilizers of the spine including rectus abdominus, transversus abdominus, internal oblique abdominals, erector spinae and multifidus muscles. Success of treatment was defined as greater than 50 % improvement from baseline to post-therapy symptoms assessed by Oswestry disability questionnaires (ODQ). Eighteen patients (33 %) were considered successes, 21 (38.9 %) patients observed improvement, while 15 (27.8 %) patients experienced less than a 6-point improvement based upon their ODQ and were quantified as failures. The authors identified four key variables as predictors of successful treatment, which included age less than 40 years old (3.7 higher odds of success), average straight leg raise at baseline, the presence of aberrant movement during lumbar range of motion, and a positive prone instability test.

The implementation of bracing has been studied to a limited degree in adults, and most data has been published in the pediatric population. Steiner and Micheli reported on 67 young adult patients with symptomatic spondylolysis or grade 1 spondylolisthesis who were treated with modified Boston bracing [6]. The average follow-up was 2.5 years. Following treatment, 52 persons (78 %) had either an excellent or good result with no pain and returned to their full activities. Nine (13 %) continued to have mild symptoms, and 6 patients (9 %) subsequently required in situ fusion. Twelve of the patients showed radiographic evidence of healing of their pars defect(s). This group and those with the best overall results tended to be men with spondylolysis and relatively acute onset of symptoms. Clinical age, delay in treatment, occurrence of spina bifida, and bone scan result did not correlate with the ultimate clinical result.

Spratt et al. evaluated the efficacy of bracing along with flexion and extension exercises for low back pain in adult patients with retrodisplacement, spondylolisthesis, and normal sagittal translation [7]. The authors set out to determine if non-operative treatment involving bracing, exercise, and education, controlling for either flexion or extension postures would result in a distinctive pattern of favorable or unfavorable results depending on the type of radiographic instability. Fifty-six patients were randomized into one of three bracing treatment groups (flexion, extension, and control). The flexion treatment group was designed to minimize lumbar extension or lordosis and each patient was fitted with a Raney Flexion Jacket and instructed by a physical therapist in proper techniques for performing a series of lumbar flexion exercises. The extension treatment group was designed to maintain lumbar extension or lordosis and was fitted a Camp hyperextension brace and instructed by a physical therapist in proper techniques for performing a series of McKenzie-type extension exercises. The control group was not provided with any information regarding flexion or extension posture and was given a Velcro wrap corset without a thermoplastic mold and was seen by a physical therapist with no specific exercise program. Patients were assessed at admission and at 1-month follow-up. The sample was relatively evenly divided between men (46 %) and women (54 %), and by age. Brace treatments were not shown to reduce patient range of motion or lessen trunk strength. Improvements were seen in VAS scores for patients braced in extension compared to those braced in flexion and in the control groups. The authors concluded that clinicians should consider extension-bracing treatment, along with complimentary education and exercise programs. This regimen may represent a relatively powerful modality and viable conservative treatment approach even for patients with chronic low back pain.

The utilization of NSAID medications has long been established as a first-line short-term therapy for the treatment of lower back pain. As a class of medication, they comprise the most commonly prescribed medication for the treatment of low back pain regardless of the specific etiology. Few studies have been published directly assessing their utilization for the treatment of spondylolisthesis. Van Tulder et al. completed a systemic review of double-blinded, randomized trials implementing NSAIDs for the treatment of low back pain [8]. Their review encompassed 51 trials totaling 6,057 patients. The authors concluded that while NSAIDs as a class were effective for the short-term relief of low back pain, in many cases paracetamol (acetaminophen) was equally as effective. In addition, it was noted that sufficient evidence advocating the use of NSAIDs for long-term therapy was not available at the time of publication.