Conservative Care for L3/L4 Spondylolisthesis With Severe Stenosis in the Setting of L5 Sacralization

Lumbosacral transitional vertebrae may alter load transfer and are associated with degenerative changes at spinal levels cranial to the transitional segment. However, the relationship between complete L5 sacralization and pathology at L3-L4 remains uncertain. We report a 69-year-old woman with chronic low-back pain, lower-extremity symptoms, and walking intolerance in the setting of complete bilateral L5 sacralization, L3-L4 grade I anterolisthesis, severe central canal stenosis, and Modic type 1 endplate changes. Given her cardiovascular comorbidity, functional goals, and preference for nonoperative care, she underwent nine months of individualized multimodal conservative management that included low-force pelvic blocking, motorized flexion-distraction therapy, radial shockwave therapy applied to symptomatic soft tissues, home advice, and progressive exercise. At month nine, pain improved from 8/10 to 1/10, lower-extremity symptoms resolved, neural-tension tests were negative, and the patient returned to unrestricted restaurant work. Follow-up magnetic resonance imaging reported L3-L4 anterolisthesis of 0.53 cm compared with 0.65 cm at baseline, together with less apparent marrow edema and facet fluid. This case documents clinical improvement during multimodal conservative care in a patient with complex degenerative lumbar pathology and complete L5 sacralization. The observed imaging differences do not establish true slip reduction, identify the effective treatment component, or confirm a causal biomechanical mechanism. Prospective studies using standardized imaging acquisition, blinded repeated measurements, and comparison groups are required.