RxHarun

Backward Slip of C4 over C5

Dr. Lisa S. Apfel MD - Spine and Neurosurgery Dr. Lisa S. Apfel MD - Spine and Neurosurgery
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Degenerative Bones, Joints, and Spine Care (A - Z)

A backward slip of C4 over C5, also known as cervical spondylolisthesis at the C4–C5 level, occurs when the fourth cervical vertebra (C4) shifts backward relative to the fifth cervical vertebra (C5). This misalignment can pinch spinal nerves or compress the spinal cord, leading to neck pain, stiffness, nerve symptoms in the arms, and in severe cases, problems with walking or bladder control.

A backward slip of the fourth cervical vertebra (C4) over the fifth (C5), medically known as cervical retrolisthesis, occurs when C4 shifts slightly backward relative to C5. This misalignment can irritate nerves, pinch the spinal cord, and lead to neck pain or neurological symptoms.

Anatomy

Structure & Location

  • Vertebral Body: The thick, cylindrical front part of each vertebra, bearing weight.

  • Pedicles & Laminae: Bony bridges connecting the body to the back part; they form the vertebral arch protecting the spinal cord.

  • Spinous & Transverse Processes: Bony protrusions for muscle and ligament attachment.

  • Intervertebral Disc: A soft cushion between C4 and C5 that absorbs shock and allows movement.

  • Facet Joints: Small joints on the back of the vertebrae guiding movement.

These structures form the C4–C5 segment in the neck, just above the shoulder region.

Origin & Insertion (Applied to Key Muscles Around C4–C5)

  1. Levator Scapulae

    • Origin: Transverse processes of C1–C4

    • Insertion: Medial border of scapula

  2. Scalenes

    • Origin: Transverse processes of C2–C7

    • Insertion: First and second ribs

(Other neck muscles share similar transverse-process origins and insert onto ribs, skull, or scapula.)

Blood Supply

  • Vertebral Arteries: Run through openings in the transverse processes of C1–C6, supplying the vertebrae and spinal cord.

  • Ascending Cervical Artery: Branch of the thyrocervical trunk, supplying muscles and soft tissues.

Nerve Supply

  • Cervical Nerve Roots (C4 & C5): Exit just above their corresponding vertebrae and innervate shoulder area, diaphragm (C4), and portions of the arm (C5).

  • Sympathetic Plexus: Wraps around vessels, conveying pain and autonomic signals.

Functions

  1. Support: Holds up the head (~10–12 pounds).

  2. Protection: Shields the spinal cord and nerve roots.

  3. Movement: Enables flexion, extension, rotation, and side bending of the neck.

  4. Shock Absorption: Intervertebral discs cushion forces.

  5. Attachment: Provides anchors for muscles and ligaments.

  6. Weight Transmission: Passes loads from head to thoracic spine.

Types of Cervical Retrolisthesis

  1. Grade I (Mild): ≤ 25% backward displacement.

  2. Grade II (Moderate): 26–50% displacement.

  3. Grade III (Severe): 51–75% displacement.

  4. Grade IV (Complete): > 75% displacement.

  5. Acute vs. Chronic: Short-term (from sudden injury) or long-standing (degenerative).

  6. Segmental vs. Multilevel: Affects one level (C4–C5) or multiple levels (e.g., C3–C4 & C4–C5).

Causes

  1. Degenerative Disc Disease – disc wear allows slippage

  2. Osteoarthritis – joint cartilage breakdown

  3. Traumatic Injury – falls or vehicle accidents

  4. Whiplash – rapid back-and-forth head motion

  5. Congenital Malformation – birth defects of vertebrae

  6. Spinal Tumors – bone erosion

  7. Infections – vertebral osteomyelitis

  8. Inflammatory Arthritis – e.g., rheumatoid arthritis

  9. Previous Spinal Surgery – instability after fusion

  10. Bone Disorders – osteoporosis or Paget’s disease

  11. Repetitive Strain – from lifting or sports

  12. Postural Imbalance – “text neck” from forward head posture

  13. Obesity – increased load on cervical spine

  14. Smoking – poor disc health

  15. Genetic Factors – familial predisposition

  16. Metabolic Disorders – e.g., diabetes affecting discs

  17. Autoimmune Diseases – affecting ligaments

  18. Vitamin D Deficiency – weak bones

  19. Muscle Weakness – poor neck support

  20. Connective Tissue Disorders – e.g., Ehlers-Danlos syndrome

Symptoms

  1. Neck pain (aching or sharp)

  2. Stiffness

  3. Headaches (base of skull)

  4. Shoulder pain

  5. Radiating arm pain

  6. Numbness or tingling in arms/hands

  7. Muscle weakness in arms

  8. Reduced neck range of motion

  9. Grinding or popping with movement

  10. Dizziness or lightheadedness

  11. Nerve “burning” sensations

  12. Balance problems

  13. Difficulty swallowing (if severe)

  14. Voice changes (rare)

  15. Fatigue (due to chronic pain)

  16. Muscle spasms

  17. Sleep disturbance

  18. Anxiety or depression (chronic discomfort)

  19. Difficulty concentrating (pain-related)

  20. Tenderness over C4–C5

Diagnostic Tests

  1. Plain X-rays (lateral, flexion-extension)

  2. Magnetic Resonance Imaging (MRI)

  3. Computed Tomography (CT) Scan

  4. Myelography (contrast dye + X-ray)

  5. Electromyography (EMG)

  6. Nerve Conduction Study

  7. Bone Density Scan (DEXA)

  8. Ultrasound (for soft tissues)

  9. Blood Tests (inflammatory markers)

  10. Bone Scan (for infection or tumors)

  11. Dynamic X-rays (motion views)

  12. Discography (disc pressurization)

  13. Tilt-Table Test (dizziness evaluation)

  14. CT-Angiography (to check vertebral arteries)

  15. Upper Endoscopy (if swallowing issues)

  16. Psychometric Testing (pain impact)

  17. Gait Analysis (balance issues)

  18. Posture Assessment

  19. Muscle Strength Testing

  20. Sensory Examination

 Non-Pharmacological Treatments

  1. Physical Therapy – stretching & strengthening

  2. Cervical Traction – gentle pulling to realign

  3. Heat Therapy – to relax muscles

  4. Cold Packs – to reduce inflammation

  5. Massage Therapy

  6. Chiropractic Adjustments

  7. Acupuncture

  8. TENS (Electrical Stimulation)

  9. Ultrasound Therapy

  10. Laser Therapy

  11. Hydrotherapy (warm pools)

  12. Cervical Collar (short-term support)

  13. Ergonomic Corrections (workstation setup)

  14. Posture Training

  15. Tai Chi

  16. Pilates

  17. Yoga

  18. Core Strengthening (to support spine)

  19. Breathing Exercises (to reduce tension)

  20. Mindfulness & Relaxation

  21. Weight Management

  22. Nutritional Counseling

  23. Kinesio Taping

  24. Dry Needling

  25. Myofascial Release

  26. Spinal Decompression Therapy

  27. Orthotic Pillows (neck support)

  28. Activity Modification

  29. Educational Programs (pain management)

  30. Biofeedback

Drugs

Drug Class Dosage (Adult) Timing Common Side Effects
Ibuprofen NSAID 200–400 mg every 6–8 h With food Stomach upset, dizziness
Naproxen NSAID 220 mg every 8–12 h With food Heartburn, headache
Diclofenac NSAID 50 mg 2–3×/day With food Liver enzyme rise, GI pain
Meloxicam NSAID 7.5–15 mg once daily Any time Edema, hypertension
Celecoxib COX-2 inhibitor 100–200 mg once daily Any time Swelling, GI discomfort
Acetaminophen Analgesic 500–1000 mg every 6 h PRN pain Liver toxicity (high dose)
Cyclobenzaprine Muscle relaxant 5–10 mg 3×/day Bedtime+morning Drowsiness, dry mouth
Methocarbamol Muscle relaxant 1500 mg 4×/day Evenly spaced Dizziness, sedation
Gabapentin Anticonvulsant 300–900 mg 3×/day Bedtime+2 others Drowsiness, ataxia
Pregabalin Anticonvulsant 75–150 mg 2×/day Morning & evening Weight gain, edema
Amitriptyline TCA 10–25 mg at bedtime Bedtime Dry mouth, constipation
Duloxetine SNRI 30–60 mg once daily Morning Nausea, insomnia
Prednisone Oral corticosteroid 5–10 mg daily tapering Morning Weight gain, mood changes
Methylprednisolone Oral corticosteroid 4–48 mg daily tapering Morning Osteoporosis, hyperglycemia
Tramadol Opioid analgesic 50–100 mg every 4–6 h PRN pain Nausea, constipation
Oxycodone Opioid analgesic 5–10 mg every 4 h PRN severe Sedation, respiratory depression
Hyaluronic Acid Viscosupplement Injection per protocol In clinic Injection site pain
Botulinum Toxin Neuromodulator 50–100 U per session Q3–4 months Weakness at injection site
Topical Lidocaine Local anesthetic Apply patch 1–3 patches PRN pain Skin irritation
Capsaicin Cream Topical analgesic Apply 3–4×/day PRN pain Burning sensation

Dietary Supplements

Supplement Dosage Function Mechanism
Glucosamine 1500 mg daily Joint support Cartilage repair & anti-inflammatory
Chondroitin 800 mg daily Disc cushion health Retains water in cartilage
Collagen Type II 40 mg daily mimic Spinal disc integrity Provides amino acids for repair
Omega-3 (Fish Oil) 1000 mg daily Anti-inflammatory Reduces pro-inflammatory cytokines
Vitamin D3 1000–2000 IU daily Bone health Enhances calcium absorption
Calcium Citrate 500 mg 2×/day Bone strength Mineral component of bone matrix
Magnesium 250 mg nightly Muscle relaxation Regulates neuromuscular transmission
Turmeric (Curcumin) 500 mg 2×/day Anti-inflammatory Inhibits NF-κB pathway
Boswellia 300 mg 3×/day Joint mobility Blocks leukotriene synthesis
Vitamin B12 1000 mcg weekly Nerve health Essential for myelin formation

Surgeries

  1. Anterior Cervical Discectomy & Fusion (ACDF) – remove disc, fuse C4–C5.

  2. Posterior Cervical Fusion – stabilize with rods and screws.

  3. Laminectomy – remove lamina to decompress cord.

  4. Foraminotomy – enlarge nerve exit holes.

  5. Total Disc Replacement – artificial disc insertion.

  6. Facet Joint Fusion – fuse painful joints.

  7. Corpectomy – remove vertebral body and fuse.

  8. Laminoplasty – hinge open lamina for space.

  9. Posterior Fixation – wire or plate fixation.

  10. Minimally Invasive Endoscopic Decompression – small incisions with camera guidance.

Prevention Strategies

  1. Maintain Good Posture – head over shoulders.

  2. Ergonomic Workstation – monitor at eye level.

  3. Regular Exercise – neck and core strengthening.

  4. Healthy Weight – reduce spinal load.

  5. Proper Lifting Technique – use legs, not back.

  6. Avoid Repetitive Strain – take breaks.

  7. Quit Smoking – improve disc nutrition.

  8. Balanced Diet – bone- and joint-friendly nutrients.

  9. Use Supportive Pillows – maintain cervical curve during sleep.

  10. Regular Check-Ups – catch early degeneration.

When to See a Doctor

  • Severe Neck Pain that lasts > 1 week

  • Radiating Arm Pain or Numbness

  • Muscle Weakness in arms or hands

  • Loss of Bowel/Bladder Control (emergency)

  • Sudden Balance Problems or difficulty walking

  • Worsening Symptoms despite home care

Frequently Asked Questions

  1. What is retrolisthesis?
    A backward shift of one vertebra over another, here C4 over C5.

  2. How is it different from spondylolisthesis?
    Retrolisthesis is backward slip; spondylolisthesis usually refers to forward slip.

  3. Can it heal on its own?
    Mild cases may improve with conservative care, but moderate to severe often need more intervention.

  4. Is surgery always required?
    No—only if conservative treatments fail or if there is severe nerve compression.

  5. How long is recovery after ACDF?
    Typically 4–6 weeks for initial healing, up to 3–6 months for full fusion.

  6. Will I have lifelong pain?
    Many patients achieve good pain relief; ongoing exercise and posture help maintain results.

  7. Are there risks with NSAIDs?
    Yes—stomach issues, kidney effects, and cardiovascular concerns with long-term use.

  8. Can physical therapy make it worse?
    If done improperly, yes. Always follow a trained therapist’s plan.

  9. What activities should I avoid?
    Heavy lifting, repetitive overhead movements, and high-impact sports during the acute phase.

  10. Is driving safe with this condition?
    Only if pain is controlled and you have full neck mobility.

  11. Do supplements really help?
    Some patients find relief; evidence is mixed. Always discuss with your doctor.

  12. What pillow is best?
    A cervical (contour) pillow supporting the natural curve of your neck.

  13. Can stress worsen symptoms?
    Yes—stress can tighten neck muscles and increase pain.

  14. How often should I get imaging?
    Only as recommended—excessive X-rays add radiation risk.

  15. Is retrolisthesis hereditary?
    Genetic factors may predispose to weaker discs or joint problems, but lifestyle plays a big role.

Disclaimer: Each person’s journey is unique, treatment plan, life style, food habit, hormonal condition, immune system, chronic disease condition, geological location, weather and previous medical  history is also unique. So always seek the best advice from a qualified medical professional or health care provider before trying any treatments to ensure to find out the best plan for you. This guide is for general information and educational purposes only. Regular check-ups and awareness can help to manage and prevent complications associated with these diseases conditions. If you or someone are suffering from this disease condition bookmark this website or share with someone who might find it useful! Boost your knowledge and stay ahead in your health journey. We always try to ensure that the content is regularly updated to reflect the latest medical research and treatment options. Thank you for giving your valuable time to read the article.

The article is written by Team Rxharun and reviewed by the Rx Editorial Board Members

Last Updated: May 06, 2025.

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References

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