What is the treatment for a 30-year-old patient with lumbar pain and a pars defect noted on X-ray (X-ray)?

From the Guidelines

Treatment for a 30-year-old with lumbar pain and a pars defect on X-ray should begin with conservative management, focusing on rest, NSAIDs, and physical therapy, with the goal of allowing healing and preventing progression to spondylolisthesis, as recommended by the American College of Physicians and the American Pain Society 1. The initial treatment approach should include:

• Rest from aggravating activities
• NSAIDs such as ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) for 1-2 weeks
• Physical therapy focusing on core strengthening and lumbar stabilization exercises, lasting 6-8 weeks with 2-3 sessions per week, and emphasizing exercises that avoid hyperextension of the spine For pain control, acetaminophen (up to 3000mg daily) can be used alongside NSAIDs. If muscle spasms are present, a short course of muscle relaxants like cyclobenzaprine (5-10mg three times daily for 7-10 days) may help. A lumbar brace or support may provide temporary relief during activities but should not be used long-term to prevent muscle deconditioning. Key considerations in managing pars defects include:
• Most pars defects respond well to conservative treatment within 3-6 months
• If pain persists despite 3-6 months of conservative management, or if neurological symptoms develop, further imaging (MRI) and surgical consultation may be warranted
• Pars defects represent a stress fracture in the vertebral arch, often from repetitive hyperextension activities, and proper management aims to allow healing while preventing progression to spondylolisthesis, as noted in the American College of Radiology's 2021 update on low back pain 1.

From the Research

Treatment Options for Lumbar Pain with Pars Defect

• Conservative management is often the first-line treatment for patients with lumbar pain and pars defect, as seen in studies 2, 3, 4.
• This approach may include the use of a custom fit thoracolumbar orthosis, activity cessation, and an organized physical therapy program, which has been shown to be effective in achieving excellent results in 95% of patients 2.
• Epidural steroid injections have also been found to be a feasible alternative to surgery in patients who fail conservative therapy, providing significant relief from chronic low back pain 5, 6.
• Surgical intervention is typically reserved for patients with refractory symptoms, severe spondylolisthesis, or considerable neurologic deficit 3, 4.
• Recent studies have highlighted the importance of prompt diagnosis and management of spondylolysis, as well as the use of advanced imaging modalities such as MRI for diagnosis 4.

Nonoperative Treatment

• A study published in the Journal of Spinal Disorders & Techniques found that nonoperative treatment with a custom fit thoracolumbar orthosis and activity cessation for 3 months, followed by an organized physical therapy program, resulted in excellent outcomes in 95% of patients with symptomatic isthmic spondylolysis 2.
• Another study published in Clinics in Sports Medicine emphasized the importance of conservative management as the first-line treatment for low-grade injuries, with surgical intervention indicated for refractory symptoms or severe spondylolisthesis 3.

Surgical Intervention

• A review published in Current Reviews in Musculoskeletal Medicine discussed the various surgical approaches to treating spondylolysis, including direct pars repair using a pedicle screw-based approach, which is preferred over spinal fusion and other direct repair techniques 4.
• The study also highlighted the importance of considering pars defect laterality, stage, and presence or absence of bone marrow edema when determining the best course of treatment 4.