What is the initial treatment for spondylolysis?

Initial Treatment for Spondylolysis

The initial treatment for spondylolysis is conservative management consisting of cessation of sports/offending activities, thoracolumbosacral orthosis (TLSO) bracing for approximately 3 months, and a structured physical therapy program focused on core strengthening, hamstring stretching, and spine range of motion exercises. 1, 2, 3

Conservative Management Protocol

Activity Modification and Bracing

• Immediate cessation of sports and activities that stress the spine is the first step 2, 3
• A custom-fit thoracolumbosacral orthosis (TLSO) should be worn for approximately 3 months 2, 3
• External bone stimulators significantly improve bony healing rates and should be prescribed alongside bracing (patients using bone stimulators showed significantly higher rates of bony healing on follow-up CT scans) 2

Physical Therapy Program

• After the initial 3-month bracing period, patients should undergo 6 weeks of structured rehabilitation 2
• The physical therapy protocol must include:
  • Core strengthening exercises 2, 4, 3
  • Hamstring stretching (hamstring tightness is a common finding) 4, 3
  • Spine range of motion exercises 4, 3

Expected Outcomes

Success Rates

• Conservative management achieves excellent outcomes in 95-98% of patients 2, 3
• Return to sports or similar activity levels occurs in 98% of patients 2
• Bony healing on follow-up CT scans occurs in approximately 50% of cases, though clinical improvement does not require radiographic healing 2

Timeline

• Initial bracing period: 3 months 2, 3
• Rehabilitation phase: 6 weeks following bracing 2
• Follow-up CT imaging at 3 months to assess bony healing 2

When Conservative Management Fails

• Only 18% of patients require facet or epidural steroid injections for continued pain after completing the conservative protocol 2
• Surgical intervention is rarely needed (less than 1% of patients) and should only be considered after exhausting conservative options 2
• Patients with persistent symptoms after conservative treatment may receive corticosteroid injections while continuing rehabilitation 2

Critical Considerations

Bracing Compliance

• While bracing is traditionally considered the mainstay of treatment, some evidence suggests that physical therapy alone (without bracing) can achieve pain relief and functional restoration in motivated patients 4
• However, the combination of bracing plus bone stimulator shows superior bony healing rates 2

Common Pitfall

• Do not proceed to advanced imaging or interventions without first completing a full 3-month conservative trial 1, 2, 3
• The most common age of injury is 15 years old, with football and weight training being the most frequent mechanisms 2
• Symptomatic spondylolysis is the most common cause of identifiable back pain in children and adolescent athletes 1