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)
Levator Scapulae
Origin: Transverse processes of C1–C4
Insertion: Medial border of scapula
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
Support: Holds up the head (~10–12 pounds).
Protection: Shields the spinal cord and nerve roots.
Movement: Enables flexion, extension, rotation, and side bending of the neck.
Shock Absorption: Intervertebral discs cushion forces.
Attachment: Provides anchors for muscles and ligaments.
Weight Transmission: Passes loads from head to thoracic spine.
Types of Cervical Retrolisthesis
Grade I (Mild): ≤ 25% backward displacement.
Grade II (Moderate): 26–50% displacement.
Grade III (Severe): 51–75% displacement.
Grade IV (Complete): > 75% displacement.
Acute vs. Chronic: Short-term (from sudden injury) or long-standing (degenerative).
Segmental vs. Multilevel: Affects one level (C4–C5) or multiple levels (e.g., C3–C4 & C4–C5).
Causes
Degenerative Disc Disease – disc wear allows slippage
Osteoarthritis – joint cartilage breakdown
Traumatic Injury – falls or vehicle accidents
Whiplash – rapid back-and-forth head motion
Congenital Malformation – birth defects of vertebrae
Spinal Tumors – bone erosion
Infections – vertebral osteomyelitis
Inflammatory Arthritis – e.g., rheumatoid arthritis
Previous Spinal Surgery – instability after fusion
Bone Disorders – osteoporosis or Paget’s disease
Repetitive Strain – from lifting or sports
Postural Imbalance – “text neck” from forward head posture
Obesity – increased load on cervical spine
Smoking – poor disc health
Genetic Factors – familial predisposition
Metabolic Disorders – e.g., diabetes affecting discs
Autoimmune Diseases – affecting ligaments
Vitamin D Deficiency – weak bones
Muscle Weakness – poor neck support
Connective Tissue Disorders – e.g., Ehlers-Danlos syndrome
Symptoms
Neck pain (aching or sharp)
Stiffness
Headaches (base of skull)
Shoulder pain
Radiating arm pain
Numbness or tingling in arms/hands
Muscle weakness in arms
Reduced neck range of motion
Grinding or popping with movement
Dizziness or lightheadedness
Nerve “burning” sensations
Balance problems
Difficulty swallowing (if severe)
Voice changes (rare)
Fatigue (due to chronic pain)
Muscle spasms
Sleep disturbance
Anxiety or depression (chronic discomfort)
Difficulty concentrating (pain-related)
Tenderness over C4–C5
Diagnostic Tests
Plain X-rays (lateral, flexion-extension)
Magnetic Resonance Imaging (MRI)
Computed Tomography (CT) Scan
Myelography (contrast dye + X-ray)
Electromyography (EMG)
Nerve Conduction Study
Bone Density Scan (DEXA)
Ultrasound (for soft tissues)
Blood Tests (inflammatory markers)
Bone Scan (for infection or tumors)
Dynamic X-rays (motion views)
Discography (disc pressurization)
Tilt-Table Test (dizziness evaluation)
CT-Angiography (to check vertebral arteries)
Upper Endoscopy (if swallowing issues)
Psychometric Testing (pain impact)
Gait Analysis (balance issues)
Posture Assessment
Muscle Strength Testing
Sensory Examination
Non-Pharmacological Treatments
Physical Therapy – stretching & strengthening
Cervical Traction – gentle pulling to realign
Heat Therapy – to relax muscles
Cold Packs – to reduce inflammation
Massage Therapy
Chiropractic Adjustments
Acupuncture
TENS (Electrical Stimulation)
Ultrasound Therapy
Laser Therapy
Hydrotherapy (warm pools)
Cervical Collar (short-term support)
Ergonomic Corrections (workstation setup)
Posture Training
Tai Chi
Pilates
Yoga
Core Strengthening (to support spine)
Breathing Exercises (to reduce tension)
Mindfulness & Relaxation
Weight Management
Nutritional Counseling
Kinesio Taping
Dry Needling
Myofascial Release
Spinal Decompression Therapy
Orthotic Pillows (neck support)
Activity Modification
Educational Programs (pain management)
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
Anterior Cervical Discectomy & Fusion (ACDF) – remove disc, fuse C4–C5.
Posterior Cervical Fusion – stabilize with rods and screws.
Laminectomy – remove lamina to decompress cord.
Foraminotomy – enlarge nerve exit holes.
Total Disc Replacement – artificial disc insertion.
Facet Joint Fusion – fuse painful joints.
Corpectomy – remove vertebral body and fuse.
Laminoplasty – hinge open lamina for space.
Posterior Fixation – wire or plate fixation.
Minimally Invasive Endoscopic Decompression – small incisions with camera guidance.
Prevention Strategies
Maintain Good Posture – head over shoulders.
Ergonomic Workstation – monitor at eye level.
Regular Exercise – neck and core strengthening.
Healthy Weight – reduce spinal load.
Proper Lifting Technique – use legs, not back.
Avoid Repetitive Strain – take breaks.
Quit Smoking – improve disc nutrition.
Balanced Diet – bone- and joint-friendly nutrients.
Use Supportive Pillows – maintain cervical curve during sleep.
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
What is retrolisthesis?
A backward shift of one vertebra over another, here C4 over C5.How is it different from spondylolisthesis?
Retrolisthesis is backward slip; spondylolisthesis usually refers to forward slip.Can it heal on its own?
Mild cases may improve with conservative care, but moderate to severe often need more intervention.Is surgery always required?
No—only if conservative treatments fail or if there is severe nerve compression.How long is recovery after ACDF?
Typically 4–6 weeks for initial healing, up to 3–6 months for full fusion.Will I have lifelong pain?
Many patients achieve good pain relief; ongoing exercise and posture help maintain results.Are there risks with NSAIDs?
Yes—stomach issues, kidney effects, and cardiovascular concerns with long-term use.Can physical therapy make it worse?
If done improperly, yes. Always follow a trained therapist’s plan.What activities should I avoid?
Heavy lifting, repetitive overhead movements, and high-impact sports during the acute phase.Is driving safe with this condition?
Only if pain is controlled and you have full neck mobility.Do supplements really help?
Some patients find relief; evidence is mixed. Always discuss with your doctor.What pillow is best?
A cervical (contour) pillow supporting the natural curve of your neck.Can stress worsen symptoms?
Yes—stress can tighten neck muscles and increase pain.How often should I get imaging?
Only as recommended—excessive X-rays add radiation risk.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.
