What to Do for Isthmic Spondylolisthesis (Grade I–II) When Structured Physical Therapy Has Not Controlled Pain
This protocol addresses patients with low-grade isthmic spondylolisthesis — Meyerding Grade I or II — who completed a structured physical therapy programme and did not achieve adequate low back pain reduction or improved lumbar range of motion.
Clinical Scenario
Isthmic spondylolisthesis arises from a defect or fracture in the pars interarticularis, often caused by repetitive mechanical stress, and frequently evolves from a pre-existing spondylolysis. Conservative management is the standard first approach for Grades I and II, particularly when there are no significant neurological deficits.
Prior Treatment & Escalation Trigger
A structured physical therapy programme of at least three weeks — encompassing core stability, strength recovery, resistance training, postural correction, and flexibility exercises — was completed. The programme did not achieve the target goals of low back pain reduction and improved lumbar range of motion. This outcome is the indication for escalation to the next management step.
Next-Step Approach
When rehabilitation alone is insufficient, an interventional procedure delivering a corticosteroid into the epidural space is considered for patients with ongoing nerve root irritation or persistent pain. The complete patient-selection criteria, procedural detail, and full management pathway are available in the structured protocol.
Treatment Goals
Short-term pain reduction and functional improvement.
References
DOI: 10.25122/jml-2025-0039Isthmic spondylolisthesis is primarily associated with a defect or fracture in the pars interarticularis, often caused by repetitive mechanical stress, and frequently progresses from a pre-existing spondylolysis.
Conservative treatment is typically recommended for patients with low-grade spondylolisthesis (grades I and II), especially those who are asymptomatic or have mild to moderate symptoms without significant neurological deficits.
For patients with isthmic spondylolisthesis, conservative treatment for three to six months has demonstrated good outcomes, managing most unilateral pars lesions and approximately 50% of bilateral lesions.
Epidural steroid injections are indicated in patients with symptomatic spondylolisthesis experiencing nerve root irritation, neurogenic claudication due to spinal stenosis, persistent pain despite NSAID use, physical therapy, and activity modification, or those who require temporary pain relief until surgery.
These injections deliver corticosteroids such as methylprednisolone into the epidural space to reduce inflammation and relieve pain.
Studies have demonstrated short-term benefits, including pain reduction and functional improvement, but long-term efficacy remains variable.
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