Treatment of Symptomatic Spondylolysis in Adolescents
Conservative management with activity cessation, thoracolumbosacral orthosis (TLSO) bracing for 3 months, and external bone stimulator followed by structured physical therapy achieves a 98% return-to-sport rate and should be the first-line treatment for all adolescent patients with symptomatic spondylolysis. 1
Initial Conservative Treatment Protocol
Phase 1: Immobilization and Bone Healing (0-3 months)
- Immediately cease all sports and athletic activities for a minimum of 3 months from diagnosis 1, 2
- Prescribe a custom-fit thoracolumbosacral orthosis (TLSO) to be worn continuously during the initial 3-month period 1, 2
- Add an external bone stimulator to the treatment regimen, as this significantly increases bony healing rates on follow-up CT scans compared to bracing alone 1
- Obtain CT imaging at 3 months to assess for bony union—approximately 50% of patients will demonstrate radiographic healing 1
Phase 2: Rehabilitation (Months 3-4.5)
- Begin a structured 6-week physical therapy program focused specifically on core strengthening exercises after the initial 3-month bracing period 1, 2
- Physical therapy should emphasize lumbar stabilization, hamstring flexibility restoration, and gradual return of range of motion 2
- Do not allow return to sports until completion of the full rehabilitation protocol 1, 2
Expected Outcomes with Conservative Management
- 95% of patients achieve excellent pain relief and resolution of back spasms with this protocol 2
- 98% successfully return to their previous level of athletic activity without requiring surgery 1
- All patients demonstrate normalization of hamstring tightness and spinal range of motion 2
Management of Treatment Failures
For Persistent Pain After Conservative Treatment
- Offer facet or epidural corticosteroid injections to the 18% of patients who experience continued pain despite completing the full conservative protocol 1
- Continue the rehabilitation program concurrently with injection therapy 1
- Only 1% of patients ultimately require surgical intervention 1
Surgical Indications (Rare)
Surgery should only be considered after documented failure of at least 6 months of comprehensive conservative treatment including bracing, bone stimulation, physical therapy, and corticosteroid injections 3, 4, 5
Surgical Options When Conservative Treatment Fails
- Pars defect repair is the preferred technique for isolated spondylolysis without significant spondylolisthesis, particularly for defects at L4 or higher levels 3
- Surgical techniques include pedicle screw-hook fixation or pedicle screw-rod constructs, which maintain spinal mobility and have low hardware failure rates 5
- In situ posterolateral L5-S1 fusion is reserved for low-grade spondylolisthesis (≤50% slip) at the lumbosacral junction that fails conservative management 3
Critical Pitfalls to Avoid
- Never allow premature return to sports before completing the full 3-month bracing period plus 6-week rehabilitation program—this is the most common cause of treatment failure 1, 2
- Do not skip the external bone stimulator—patients who use bone stimulators as prescribed demonstrate significantly higher rates of bony healing 1
- Avoid proceeding to surgery without documenting at least 6 months of failed conservative treatment including all components: bracing, bone stimulation, physical therapy, and consideration of injections 3, 4, 5
- Do not rely solely on radiographic healing to determine return-to-play readiness—clinical resolution of symptoms and completion of rehabilitation are equally important, as only 50% achieve bony union but 98% return to sports successfully 1
Monitoring During Treatment
- Obtain baseline imaging with plain radiographs followed by MRI to confirm diagnosis 1
- Mandatory 3-month follow-up CT scan to assess bony healing status 1
- Serial clinical assessments should document resolution of back spasms, improvement in hamstring flexibility, and restoration of normal spinal range of motion 2