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Treatment Options for Spondylolysis

Patients with asymptomatic spondylolysis require no treatment. Follow-up radiographic imaging should be performed every six months during skeletal growth to track the status of the pars. Individuals with symptomatic spondylolysis may be managed conservatively without surgery. Treatment includes:

• Restriction of strenuous activity
• Short course of bed rest
• Mild analgesics
• A physical therapy program to strengthen abdominal and spinal muscle tone as well as stretching muscles for increased tone
• Lifestyle modifications - including maintaining proper weight with diet, exercise and cessation of smoking
• Orthosis or brace to correct lordosis of lumbosacral area, to provide support, and to reduce pain
• Surgical repair the pars is considered only if conservative management fails to relieve symptoms. Children may need to wear a brace following surgery. Older patients or patients with spinal instability may require surgical fusion.

Most patients (estimates range between 65% and 80%) respond to conservative treatment with total resolution of symptoms. When the pain goes away, the individual can resume all activities including sports. Following severe pain, many physicians recommend waiting about 3 months before resuming activities. If pain is severe in a child, a bone scan can determine if there is a defect in the pars.

Treatment of Grades I/II Spondylolisthesis

Grades I and II slippage are usually treated with conservative treatment, namely analgesics, rest, weight loss if applicable, and physical therapy. However, if these efforts are not effective, additional intervention may be needed including:

• X-rays every 3-6 months to check for progression of slip for children before skeletal maturity
• Rigid bracing or body cast
• Intensive physical therapy to strengthen the back and abdominal muscles. Supervised rehabilitation may require 3 months or longer.
• Exercise program to stretch hamstring muscles
• Period of resting and abstaining from sports

A child with low-grade spondylolisthesis who responds to conservative treatment can return to some sports activities, although some types of sports (e.g., gymnastics and weight lifting) may exacerbate the patient's prior symptoms and may need to be restricted for a longer duration.

If an adolescent develops spondylolisthesis due to an acute injury, there has been some success reported by placing the patient in a custom-made orthosis with the lumbar spine in a position of extension for 2 to 3 months to achieve healing of the fracture and relieve symptoms. However, the effectiveness of orthosis remains an area of debate. Some older patients with low-grade slips benefit from traction. Traction should always be administered under the care of a physician or physical therapist.

If pain does not improve with conservative treatment, surgery may have to be considered. The younger the age of onset, the greater the risk for slip progression and these patients should be monitored on a periodic basis even if the initial symptoms resolve. Skeletally immature children with slippage greater that 30-50% are at increased risk for progression. It has been estimated that up to 50% of individuals with Grade II spondylolisthesis will eventually require surgery, usually fusion with or without pars repair. If there are neurological symptoms, decompression (laminectomy) may be necessary.