Treatment for Spondylolysis
Initial treatment for spondylolysis consists of cessation of sports/aggravating activities, physical therapy focused on core strengthening and hamstring stretching, and thoracolumbosacral orthosis (TLSO) bracing for 3 months, which achieves successful clinical outcomes in 84% of patients. 1
First-Line Conservative Management
The cornerstone of treatment is a structured conservative approach that should be maintained for 3-6 months before considering any alternative interventions:
Activity Modification
- Immediately cease all sports participation and activities that cause pain (particularly extension-based activities like gymnastics, football, weight training, and diving). 2, 3
- The highest incidence of spondylolysis injuries occurs in the first quarter of the year, with March being peak injury month, most commonly affecting 15-year-old athletes. 3
Bracing Protocol
- Apply a thoracolumbosacral orthosis (TLSO) for 3 months continuously. 3, 1
- While bracing does not significantly influence clinical outcomes compared to non-braced treatment (P=0.75), it remains standard practice in most protocols. 1
- Important caveat: Some evidence suggests that physical therapy alone without bracing can achieve 96% minimal disability outcomes, making bracing optional in compliant patients who can adhere to activity restriction. 4
Physical Therapy Program
- Initiate a structured 6-week rehabilitation program focusing on:
- Flexion-based exercises are superior to extension exercises: patients performing flexion routines have only 19% moderate/severe pain at 3-year follow-up versus 67% in extension exercise groups. 5
- Avoid maximal forward flexion of the lumbar spine during acute phases. 5
Adjunctive Treatment
- External bone stimulator use for 3 months significantly increases bony healing rates on follow-up CT scans compared to non-users. 3
- 152 of 201 patients (75%) who used bone stimulators as prescribed showed significantly higher healing rates. 3
Expected Outcomes and Monitoring
Clinical Success Rates
- 83.9% of patients achieve successful clinical outcomes with conservative treatment (pooled data from 665 patients). 1
- 98% return to sports or similar activity levels after completing the conservative protocol. 3
- 78% of patients achieve complete pain resolution (disability score of zero). 4
Radiographic Healing Patterns
- Overall bony healing occurs in only 28-50% of cases, but clinical success does not depend on radiographic healing. 3, 1
- Unilateral defects heal at 71% versus bilateral defects at 18.1% (P<0.0001). 1
- Acute lesions heal at 68.1% versus progressive lesions at 28.3%, while terminal/chronic lesions show 0% healing. 1
- Obtain CT scan at 3-month follow-up to assess bony healing status. 3
Management of Persistent Symptoms
For Patients Not Improving After 3-6 Months
- 18% of patients require facet or epidural corticosteroid injections for continued pain after completing the initial conservative protocol. 3
- Continue rehabilitation protocol even after steroid injection. 3
- Only 1-2% ultimately require surgical intervention. 3
Critical Contraindications
- Do not use systemic glucocorticoids for axial spinal conditions—they provide no proven benefit. 6, 7
- Avoid spinal manipulation in patients with spondylolysis due to structural instability risk. 8
Common Pitfalls to Avoid
- Do not obtain routine repeat imaging at scheduled intervals for stable patients; only repeat imaging if new neurologic symptoms, significant functional decline, or clinical progression occurs. 8
- Do not rush return to sports: the minimum conservative trial period should be 3-4 months before considering the patient treatment-resistant. 5
- Do not assume radiographic healing is necessary: 72% of successfully treated patients show no bony healing on imaging yet remain asymptomatic. 1
- Do not prescribe extension-based exercises: these lead to significantly worse long-term pain outcomes compared to flexion-based programs. 5