Spondylolysis and spondylolisthesis in child and adolescent athletes: Management

INTRODUCTION — Among child and adolescent athletes, spondylolysis typically represents a fracture of the posterior arch in the lower lumbar spine due to overuse and is a relatively common cause of low back pain. Spondylolisthesis involves anterior displacement of a vertebral body due to bilateral defects of the posterior arch and is less common than spondylolysis. In the large majority of cases, treatment consisting primarily of rest and symptom management allows children and adolescents to recover from these conditions without complications.

The management of spondylolysis and spondylolisthesis in child and adolescent athletes is reviewed here. The clinical presentation and diagnosis of these conditions, and the assessment of unspecified back pain in children, are discussed separately. (See "Spondylolysis and spondylolisthesis in child and adolescent athletes: Clinical presentation, imaging, and diagnosis" and "Back pain in children and adolescents: Evaluation" and "Back pain in children and adolescents: Causes".)

INITIAL MANAGEMENT WHEN SPONDYLOLYSIS IS SUSPECTED

Ruling out dangerous causes of back pain — Patients, particularly younger children, with a potentially dangerous cause of low back pain must be worked up appropriately; their care is reviewed in detail separately. (See "Back pain in children and adolescents: Evaluation".)

Symptoms and signs associated with dangerous causes of back pain include:

●Age less than four years

●Fever

●Weight loss

●Severe, constant, or steadily worsening pain

●Nocturnal pain

●History of trauma

●History of malignancy

●History of tuberculosis disease or exposure

●Evidence of neurologic dysfunction

In addition, it is important to consider alternative causes of back pain, particularly if imaging studies are to be deferred. Examination of the integument for café au lait spots that might suggest an underlying neurofibromatosis and the area between the buttocks for dimples or tufts of hair suggesting occult spina bifida or other congenital anomaly are cutaneous findings often over-looked during the general examination. The clinical manifestations and diagnosis of spondylolysis and spondylolisthesis in child and adolescent athletes are reviewed separately. (See "Spondylolysis and spondylolisthesis in child and adolescent athletes: Clinical presentation, imaging, and diagnosis".)

Initial evaluation and observation — A flow chart that outlines the evaluation and management of patients with suspected spondylolysis is provided in the following document (algorithm 1). Patients suspected of having spondylolysis but who are free of symptoms or signs suggesting other high-risk conditions or radiculopathy, are typically observed for two to four weeks and instructed to refrain from inciting activity. There is little data to help determine the ideal period of activity restriction, but clinical experience suggests that two to four weeks are reasonable [1]. Patients whose symptoms resolve often have nonspecific muscular back pain and may resume activity. These patients should be reassessed if pain recurs. Patients whose symptoms do not improve after two to four weeks of relative rest, or in cases where the patient or family refuse to limit activity, are re-examined and assessed with diagnostic imaging. The approach to imaging patients with suspected spondylolysis or spondylolisthesis is discussed separately; the next stage of management is described below. (See "Spondylolysis and spondylolisthesis in child and adolescent athletes: Clinical presentation, imaging, and diagnosis", section on 'Approach to imaging for spondylolysis' and 'Management of patients with spondylolysis established clinically or radiographically' below.)

INDICATIONS FOR SPINE SURGERY REFERRAL — If at any point during management, a patient with spondylolysis or spondylolisthesis begins to manifest signs of neurologic injury, including lumbosacral radiculopathy or any other abnormal neurologic findings, immediate consultation with a spine surgeon is required. The general indications for referral are described separately. (See "Spondylolysis and spondylolisthesis in child and adolescent athletes: Clinical presentation, imaging, and diagnosis", section on 'Indications for surgical referral'.)

MANAGEMENT OF PATIENTS WITH SPONDYLOLYSIS ESTABLISHED CLINICALLY OR RADIOGRAPHICALLY

Overview and principles of management — Evidence pertaining to the nonoperative management of spondylolysis and spondylolisthesis is extremely limited. Thus, the approach described below is based primarily upon observational studies and our clinical experience. A flow chart that outlines the evaluation and management of patients with suspected spondylolysis is provided in the following document (algorithm 1).

The large majority of children who develop spondylolysis or spondylolisthesis do well with simple rest and symptom management, and thus, it is usually best to avoid aggressive interventions. A comprehensive review of studies of elite young athletes that assessed conservative versus surgical treatment in spondylolysis and low grade spondylolisthesis found no difference in clinically important outcomes at one year follow-up [2]. Similar outcomes were reported in a prospective study published after this review of 149 young patients with spondylolysis, although the study noted a higher rate of complications among surgical patients [3].

Relative rest is often the most effective treatment for children and adolescents with spondylolysis or low-grade spondylolisthesis [4-6]. The ideal period of relative rest is not well studied or defined. Ninety days is reasonable in most cases, but this period is often modified depending upon the patient’s symptoms, age, and activities.

Most knowledgeable clinicians agree that asymptomatic children or adolescents who are inadvertently imaged and given the diagnosis of spondylolysis should not be restricted in any way [4,5,7,8]. Patients with spondylolisthesis that progresses to Grade II or beyond should be referred to a spine surgeon for management and told to refrain from all strenuous activity until consultation is obtained. Likewise, any patient who develops a motor deficit or any other concerning neurologic finding should be referred to a spine surgeon immediately. (See "Spondylolysis and spondylolisthesis in child and adolescent athletes: Clinical presentation, imaging, and diagnosis", section on 'Indications for surgical referral'.)

When determining the course of management, a major consideration is the patient and parents’ willingness to restrict activities and their anticipated compliance with these restrictions. We recommend having a frank discussion with any young athlete and their family about the risks entailed by continued activity and associated with any proposed or potential imaging studies (eg, radiation) [9,10]. Such discussion enables them to make an informed decision about management. (See "Spondylolysis and spondylolisthesis in child and adolescent athletes: Clinical presentation, imaging, and diagnosis", section on 'Diagnostic imaging'.)

In the past, treatment decisions were predicated on the need to achieve full bony healing and involved prolonged use of a lumbar brace. Subsequent research and experience suggests that such a conservative approach is unnecessary, as bony healing is not necessary for a good outcome and may not be possible in some cases [4,5,7,11]. Several studies report good outcomes without bracing, and many patients go on to non-bony fibrous union and do well. (See 'Bracing' below.)

It is difficult to draw inferences about the best approach to the nonoperative management of spondylolysis and spondylolisthesis. Few studies differentiate among the five types of spondylolysis and spondylolisthesis, and studies often involve different etiologies, treatments, and outcomes. This makes it difficult to sort out the best course of action for adolescent athletes with isthmic spondylolysis (the most common form of spondylolysis among adolescents) [4,5,7]. In addition, studies devoted to adolescents generally do not report outcomes by Tokushima Classification [7]. (See "Spondylolysis and spondylolisthesis in child and adolescent athletes: Clinical presentation, imaging, and diagnosis", section on 'Classification'.)

First follow-up visit for patients with persistent pain — Our approach to the child or adolescent with clinical spondylolysis (ie, persistent lumbosacral pain aggravated by lumbar extension despite four weeks of appropriate rest) is described here. This approach is not appropriate for patients under six years, or for those with an abnormal neurologic examination possibly including radicular symptoms and signs, significant back or pelvic trauma, or patients with symptoms that suggest a need for further evaluation to assess for an atypical cause of back pain rather than spondylolysis. A flow chart that outlines the evaluation and management of patients with suspected spondylolysis is provided in the following document (algorithm 1).

At the first follow-up visit, we review the history, again checking to be sure no symptoms or signs that suggest more severe disease are present, repeat a physical examination, and perform the screening assessments outlined immediately below, including plain radiographs. The differential diagnosis and examination of these patients is reviewed in detail separately. (See "Spondylolysis and spondylolisthesis in child and adolescent athletes: Clinical presentation, imaging, and diagnosis", section on 'Differential diagnosis' and "Spondylolysis and spondylolisthesis in child and adolescent athletes: Clinical presentation, imaging, and diagnosis", section on 'Clinical presentation and examination'.)

●Obtain AP and standing lateral radiograph of lumbosacral (LS) spine (only 1.5 mSv; no oblique or thoracic views)

●Screen for hypermobile syndrome using Beighton Score (table 1) (see "Clinical manifestations and diagnosis of hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorder")

●Assess muscle strength and flexibility

•Hamstring: popliteal angle (picture 1 and figure 1)

•Psoas/Thoraco-lumbar flexibility (picture 2)

•Abdominal strength (eg, timed plank (picture 3); abdominal crunch against resistance (picture 4))

•Gluteal strength (one-leg squat (picture 5))

●Assess sleep quality

●Take a family history: first-degree relative with diagnosis of isthmic spondylolysis; Native Inuit

We do not obtain oblique or stress views of the LS spine because of the radiation exposure to young patients. The screening tests and assessments listed above help us to determine management and prognosis. A child’s mobility is genetically determined to a large extent but may change during different phases of growth (eg, decreased mobility in late adolescence is common). Nevertheless, we have found that patients with a Beighton score over 5 (table 1) are at increased risk of recurring pain if they return to full activity too early. Measures of muscle strength and flexibility and of sleep quality provide a baseline as patients resume full activity. (See 'Patients with hypermobility' below.)

Patients with a first-degree relative diagnosed with isthmic spondylolysis or of Native Inuit ancestry are at increased risk for spondylolysis and are managed more conservatively than other populations. We suggest that for this higher risk group, advanced imaging (eg, magnetic resonance imaging [MRI]) be obtained early.

Treatment by radiograph findings and patient willingness to rest — After performing the assessment described immediately above, we determine a treatment plan in collaboration with the patient and family. For patients with persistent symptoms following the initial two- to four-week rest and observation period, treatment is based upon the findings on the plain radiographs of the LS spine and the patient’s willingness to comply with our recommendation for prolonged (approximately 90 day) relative rest. Provided the athlete was compliant, the initial two- to four-week rest period may be counted towards the 90 days of prolonged rest [12].

If the LS radiographs show spondylolisthesis beyond Grade I, we refer the patient to a spine surgeon experienced in the management of this condition. (See "Spondylolysis and spondylolisthesis in child and adolescent athletes: Clinical presentation, imaging, and diagnosis", section on 'Indications for surgical referral'.)

If the LS radiographs show spondylolysis or Grade I spondylolisthesis, we recommend a 90-day period of relative rest. Daily activities and many cardiovascular and strength training exercises are allowed provided the patient remains pain-free throughout and following the activity. Weight lifting and sport activity must be modified to avoid all lumbar extension. Deadlifts and similar exercises are not permitted initially nor are any sport movements involving lumbar extension (eg, tennis serve, back flip, sled blocking in American football).

If the LS radiographs are negative, we give the patient and family a choice, but we still recommend a 90-day trial of relative rest with monthly follow-up. Low-risk sport activity that does not place undue stress on the lumbar spine or involve lumbar extension can continue as long as the athlete does not see an increase in pain with the sport or increasing delayed-onset pain in the 24 to 48 hours post activity.

For all athletes, we stipulate the following conditions during the 90-day rest period:

●The patient must avoid any "high-risk" activity that may aggravate their pain, including all activities requiring lumbar extension.

●The patient must agree not to withhold complaints of pain or worsening of any symptoms from their parents, coach, and healthcare providers.

●If the patient is uncomfortable during a normal daily activity (walking at school, cleaning their room), they must refrain from all athletic activity.

●The patient and family should work together to ensure good nutrition and sleep hygiene, and that all recommended strength and flexibility exercises are performed as prescribed. Any psychological difficulties that develop, including persistent mood changes, are to be discussed; appropriate cognitive therapy may be recommended.

Intense athletic activity is not permitted, but once symptoms have resolved, most patients can perform light activities that do not involve lumbar extension provided they do not cause pain. As examples, basketball players can continue to shoot, and tennis players usually can hit backhands, forehands, and volleys but no serves or overheads. Such activity constitutes relative rest while allowing the athlete to remain in better condition and feel less restricted.

Despite our clear recommendations, some patients and their families wish to continue playing their sport and prefer not to observe a prolonged period of rest (activity restrictions are reviewed no sooner than every 30 days in cases where radiographs are negative; 90 days of relative rest is the general rule when radiographs are positive). In these cases, we believe it is important to obtain advanced imaging, with MRI being the study performed most often. MRI is generally preferred in younger patients due to the absence of radiation exposure. Some clinicians may use single-photon emission computed tomography (SPECT), which offers some advantages when plain radiographs suggest a possible osteoid osteoma or anomalies in the lumbar spine. Our approach to imaging patients with suspected spondylolysis and spondylolisthesis is described separately. (See "Spondylolysis and spondylolisthesis in child and adolescent athletes: Clinical presentation, imaging, and diagnosis", section on 'Approach to imaging for spondylolysis'.)

For patients who continue participating in sports despite our stated preference, we often suggest they use a soft corset-type lumbar brace during activity. While relatively soft and non-restricting, these braces have more rigid material on the posterior portion so the patient feels mild pressure whenever she or he extends their lumbar spine. Thus, the brace serves as a tactile reminder to limit such extension. For all patients, our approach to symptom control remains the same. (See 'Bracing' below.)

Symptom control and basic treatment — There is little published evidence concerning the best approach to symptom management in children and adolescents with spondylolysis or spondylolisthesis. The author’s basic approach includes several interventions:

●Position and stretching exercises (see 'Physical therapy' below)

●Applying ice to areas that become acutely symptomatic with activity

●Occasional use of warm showers or baths, if these provide relief

●Over-the-counter (OTC) analgesics (eg, acetaminophen)

●Topical capsaicin

Although this simple approach helps many patients, it is not exhaustive and experienced clinicians may have found other interventions to be helpful.

A number of clinicians have patients use the positions and stretching exercises shown in the attached pictures, and we have found they afford some patients limited relief (picture 6 and picture 7). In addition, such exercises allow the patient a form of nonpharmacologic pain relief under their control. Ice may be applied when pain develops for 15 to 20 minutes at a time on an hourly basis, taking care to avoid direct contact with the skin, which can cause cold-related injury. Although we prefer acetaminophen for analgesia, evidence that nonsteroidal antiinflammatory drugs (NSAIDs) impair bone healing in these patients is limited, and a short course of NSAIDs to manage pain is reasonable. (See "Nonselective NSAIDs: Overview of adverse effects", section on 'Possible effect on fracture healing'.)

We routinely evaluate the quality of our patient’s sleep, as we believe this problem is often overlooked in young patients with spondylolysis. Our preference is an average of eight hours of high-quality sleep each night at least until the patient is symptom-free. (See "Assessment of sleep disorders in children".)

Return to play — Return-to-play decisions are clear in most cases. The large majority of patients with spondylolysis or low grade spondylolisthesis, regardless of radiographic findings, do well if they observe an appropriate period of relative rest and return to full sport activity gradually, as prescribed by the clinicians supervising their care. A gradual return to full sport begins after an appropriate period of relative rest (usually 90 days) has been completed and the patient is symptom-free.

Controversy exists about the efficacy of lumbar bracing to limit motion of the LS spine during sport activity. Theoretically, a rigid brace interferes with the fluid movement and coordination of the upper and lower extremities, indirectly affecting the biomechanics of the LS spine [4]. For this reason, we do not advocate the use of rigid back braces when the athlete returns to sport.

Our basic scheme for rehabilitation and helping athletes return to play is as follows:

●Step 1 (approximately one month in duration; typically begins during the period of relative rest) [12-14]

•To participate, the patient must demonstrate that they can perform an abdominal crunch without pain, and that they can walk without pain or limp. If so, the patient begins performing core strengthening exercises (eg, planks (picture 3 and picture 8), bridges (picture 9)) daily. Pain and the ability to stabilize the LS spine during these exercises, rather than any particular timeframe, should determine whether an athlete is ready to perform them. Particularly if these exercises are started early during step 1, the athlete should be supervised.

Low intensity aerobic activity is performed for 30 to 45 minutes daily (eg, walking or biking). Running and swimming are not permitted.

•Spondylolytic conditions take a toll on adolescents not only physically but also psychologically and socially. To address this, we advocate that athletes continue to spend time with their team (eg, participate in team meetings, attend games on the sideline) and to receive education and counseling as needed. This can help to minimize catastrophizing and other harmful psychological effects.

●Step 2 (approximately one month in duration following completion of step 1; may overlap with final stages of relative rest period)

•To advance to step 2, the patient must demonstrate that they no longer experience pain with hopping, normal back motions, and when performing a one leg hyperextension test.

•Continue core strengthening exercises. Add weight lifting with back supported to prevent any lumbar extension beyond neutral. Include deadlifts with light weight to begin rehabilitation of hip and back extensors. Continue aerobic activity; okay to perform any such activities that do not cause pain. Patient can begin performing sport-specific drills that are low risk (eg, ground strokes in tennis, shooting drills in basketball, forward tumbling in gymnastics).

●Step 3 (approximately one month in duration following completion of step 2)

•To advance to step 3, the patient must demonstrate pain-free running and jumping, as well as pain-free back extension.

•Continue core strengthening exercises. Advance weight exercises as needed for sport. Gradually and cautiously, increase the weight used for weight-lifting exercises.

•Begin normal sport activities, but avoid any involving full contact. If the patient remains pain-free, the level of activity is increased weekly and more intense sport-specific drills are performed. At the end of this stage, full participation, including full contact for contact sports, is permitted to determine whether the patient can perform without pain. If not, step 3 of the recovery is extended for two weeks using exercises just short of full participation that do not cause pain, and then the athlete is reassessed.

The timeframe for return to graded activity varies, but a number of studies suggest that two to four months is the average for patients with uncomplicated spondylolysis [15,16]. In our clinics, the typical patient returns to full sport activity in 12 weeks, but less time may be needed for participants in low-risk sports. More severe, symptomatic cases of spondylolisthesis may require much longer. Input from physical therapists and athletic trainers is often important for determining when a patient can progress to more vigorous activity. A number of studies have used pain questionnaires to evaluate patients [15-18]. These studies suggest that approximately 80 to 90 percent of patients with spondylolysis and spondylolisthesis treated conservatively return to activity within five to six months. Eighty to 100 percent of patients requiring surgery return to sports in 6 to 12 months [15]. (See 'Prognosis and complications' below.)

In our experience, the main reasons why treatment is unsuccessful are noncompliance with activity restrictions and failure to improve core and gluteal strength. Weak core and gluteal muscles fail to maintain the pelvis and lumbar spine in neutral positions, and such positioning is important for treatment and reducing the risk of recurrent injury. Even participants in relatively low-risk sports may have difficulty returning to play without improving their core and gluteal strength, and we do not permit our athletes to return to play until they demonstrate sufficient strength to stabilize their lumbar spine and pelvis.

A patient’s stage of physical development is another important factor that affects the time needed before a full return to play. Patients who are past their adolescent growth spurt, remain asymptomatic and demonstrate good core strength following rehabilitation, and participate in low-risk activities have the best prognosis and generally return to sport quickly (less than 12 weeks). At the opposite end of the spectrum, athletes who have not begun their adolescent growth spurt and play high risk sports are at greatest risk for persistent or possibly progressive symptoms, and typically require the longest time before returning to sport (often four to six months). We manage these patients conservatively and explain to them and their parents that they will not return to play during the current season and to expect a longer recovery period. In addition, we encourage such young athletes to participate in a wide range of sports after they recover (ie, avoid early specialization), including lower risk activities.

Patients with hypermobility — Patients with a high Beighton Score (table 1) suggesting the presence of a hypermobility syndrome can be more difficult to manage. This group appears to have greater trouble returning to high-demand sports (eg, gymnastics, American football linemen) (table 2). We manage these patients conservatively. Patients with hypermobility syndromes may have symptoms of spondylolisthesis with no findings on routine plain films. However, flexion and extension views of the lumbar spine may show a dynamic spondylolisthesis related to ligamentous laxity. Genetic syndromes such as Ehlers-Danlos or Marfan may be the source of problems in this group. We suggest referring patients with a Beighton score of 5 or greater and those who manifest suggestive skin changes (eg, laxity, piezogenic papules on heels, fragile or “velvety” skin) and are diagnosed with spondylolysis or spondylolisthesis for genetic evaluation. (See "Spondylolysis and spondylolisthesis in child and adolescent athletes: Clinical presentation, imaging, and diagnosis", section on 'Epidemiology and risk factors' and "Clinical manifestations and diagnosis of Ehlers-Danlos syndromes" and "Genetics, clinical features, and diagnosis of Marfan syndrome and related disorders" and "Clinical manifestations and diagnosis of hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorder".)

Bracing — Spondylolysis and bone stress reaction at the isthmus may be a more common condition than was once believed, with most patients remaining asymptomatic [4,19]. Those that become symptomatic usually have excellent outcomes when activity is restricted either by their healthcare provider or because of discomfort [20]. For patients who are unable or unwilling to restrict their activity, bracing may be of benefit [4]. Our use of bracing is integrated into the discussion of treatment found in this topic, but for the large majority of our patients we do not advocate bracing. The different approaches to bracing patients with spondylolysis and low grade spondylolisthesis are reviewed below.

Lumbar bracing has been a mainstay of treatment for patients with isthmic spondylolysis for many years in the United States [11,21,22]. In older protocols using the Boston Brace (picture 10), patients were braced 23 hours a day for three months and, if they improved, were then allowed to wean off the brace over three months [23]. Many patients in many countries have achieved excellent results with this or similar regimens [24,25]. Proponents claim that the rate of bony healing for pars fractures improves when the Boston Brace protocol is followed, but this claim has not been verified in outcome studies.

Despite the prominent role of the Boston Brace in the past, the authors of several studies and many other clinicians have challenged traditional approaches to bracing, believing that many adolescent patients have difficulty following protocols that require spending 23 hours a day in a brace [4,5,7]. Some researchers have raised questions about compliance and reported that patients frequently stop wearing their brace, while others have difficulty refraining from competitive activity [4,26]. Furthermore, lengthy periods (eg, several months) spent wearing a brace can decondition muscles, particularly those of the back and torso [4,26].

In addition to these clinical limitations, braces may not accomplish what advocates purport them to do biomechanically. Several studies have reported that sacral orthoses and corsets are ineffective at limiting spinal motion distal to the L4-L5 (L4 isthmus) level [27,28]. The authors of one meta-analysis of the bracing literature propose that it is activity restriction rather than bracing that is responsible for improvements in these patients [4].

Among researchers who advocate bracing, debate continues about the best approach. Most studies promote anti-lordotic bracing, and supporters of this approach believe that placing the lumbar spine in kyphosis relieves stress on the pars, thereby promoting healing [24]. However, others advocate lordotic bracing, believing that maintaining the lumbar spine in lordosis and thereby loading the posterior spine enhances healing [19]. Yet other clinicians have advocated the use of a “soft” corset-type brace that positions the spine in a neutral position during the period when patients with spondylolysis observe relative rest [4]. The range of proposed mechanisms and approaches suggests that our understanding of bracing remains limited.

The theory behind soft braces is that more restrictive material is placed on the posterior portion of the brace so that the patient feels some pressure with back extension. Proprioceptive feedback leads the athlete to limit such extension but does not physically restrict motion.

Adjunctive treatments

Vitamin D — We believe it is reasonable to measure serum vitamin D concentrations in patients with isthmic spondylolysis and to provide supplementation if measurements are low. In such cases, we give supplemental calcium as well. There is no high-quality evidence supporting prophylactic treatment with vitamin D in patients with spondylolysis [29-31]. If the clinician has concerns about the patient’s nutrition, a dietary consult can be helpful. Vitamin D deficiency and the role of vitamin D in fracture healing are discussed separately. (See "Vitamin D insufficiency and deficiency in children and adolescents" and "General principles of definitive fracture management", section on 'Adjunctive therapy for fracture healing'.)

Physical therapy — Although not mandatory, many clinicians use physical therapy and similar rehabilitative techniques to help patients with spondylolysis return to activity [4,32,33]. This may be done through a formal physical therapy referral or as a home-based exercise program monitored by the clinician. For patients with more severe symptoms or those not improving with a home-based regimen, referral to a knowledgeable physical therapist is often helpful. Our scheme for helping young athletes to recover and return to play is described above. (See 'Return to play' above.)

We prescribe several basic exercises to all patients with spondylolysis as part of a home exercise program (picture 6 and picture 7). In addition, once the patient can perform basic movements without pain, exercises to strengthen the core and gluteal musculature are introduced (picture 8). These exercises may include plank (picture 3), bridge (picture 9), and squat variations (picture 11 and picture 12 and movie 1 and picture 13 and picture 14) with demands and loads that gradually increase as the patient’s strength improves. A more detailed core exercise program for spondylolysis can be found in the following reference [33]. Most physical therapy programs for young patients with spondylolysis focus on increasing core, pelvic, and gluteal strength, and hamstring flexibility, if underlying tightness is identified. In addition to these exercises, we encourage patients to perform regular cardiopulmonary exercise.

Other clinicians take a different approach to physical therapy. Initially, they may prohibit all exercises involving back extension other than pelvic tilts and use only isometric abdominal and pelvic core exercises to promote core strength and spine stability. Gradually, exercises involving motion, primarily at the hip, are introduced, provided the patient can perform them without pain. As exercises become easier, more challenging ones are introduced, again, provided the patient can perform them pain-free. Typically, after about six weeks, exercises involving back extension may be started. Such exercises involve movement to but never beyond a neutral standing position (ie, lumbar hyperextension is never permitted). An example would be deadlift exercises (picture 15 and picture 16) performed with relatively light weight.

Evidence supporting the use of physical therapy to treat spondylolysis is limited [4,7,34]. Studies of rehabilitation rarely distinguish among the various types of spondylolysis patients, nor do they specify the type of physical therapy program used [4,7]. Nevertheless, a few studies support the use of physical therapy in these patients, including those described below.

A randomized trial of 44 patients with spondylolysis or spondylolisthesis compared a physical therapy program focused on core-strengthening exercises with one using general conditioning exercises [26]. The specific core-strengthening program involved training the patients to contract their deep abdominal muscles, while inhibiting their larger “torque”—producing muscles (rectus abdominis and external obliques), using surface electromyelogram (EMG) and biofeedback techniques. As training progressed, patients were challenged to maintain good posture in increasingly difficult situations (eg, walking, flexing the lumbar spine, performing their job). Patients managed with the specific program showed statistically significant reductions in pain and disability compared to those treated with general conditioning that persisted at 30 month follow-up. This program parallels others that emphasize core strength exercises. While most clinicians and therapists do not have access to surface EMG and biofeedback equipment, a progression of comparable exercises can be used to help patients strengthen the muscles that support their spine and ultimately enable a return to active sport participation [32,35].

A study of 31 patients with lumbar spondylolysis or a spondylolisthesis used motion analysis to try to quantify abnormal lumbar motion [36]. Patients with isthmic spondylolysis manifested a “hypermobile” spine when studied using a triaxial potentiometric computerized motion analysis system. This finding suggests that improving a patient’s ability to monitor their spine position and maintain a neutral spine during activity would be useful. Physical therapy can help patients develop the body awareness and strength to achieve these goals.

Follow-up

Clinic visits and reassessments — There are no published recommendations on when or how often patients with spondylolysis and spondylolisthesis should be seen in follow-up. The follow-up period varies depending upon the severity of the patient’s symptoms, the speed with which they desire to return to play, and the nature of their pathology (eg, presence of spondylolisthesis). We follow patients every 20 to 30 days during the period of relative rest that we recommend, which typically lasts 90 days. After an initial period of rest, patients who are symptom-free and manifest no tenderness or pain with provocative maneuvers (eg, lumbar extension tests) or basic physical activities (eg, running) are cleared to begin a graduated program that will return them to sport. Typically, we do not perform further imaging. (See 'Return to play' above and 'Surveillance imaging' below.)

During the transition to full sport, we follow patients a bit more closely, often with the assistance of coaches and trainers, and usually schedule follow-up visits every 10 to 20 days. The transition to full sport typically takes 30 to 90 days. More time is often needed for patients who had a more difficult course (eg, severe or recurring symptoms) or are returning to a relatively high risk activity that will place greater stress on their lumbar spine (eg, gymnastics, American football, wrestling). With patients who are doing well, some formal follow-up clinic visits can be replaced by reports or visits with other health team members (eg, athletic trainer). (See "Spondylolysis and spondylolisthesis in child and adolescent athletes: Clinical presentation, imaging, and diagnosis", section on 'Epidemiology and risk factors'.)

Following a patient’s return to full sport, we schedule monthly follow-up visits, during which we assess pain, sleep quality, and muscle strength and flexibility each time. If return to play prompts a recurrence of symptoms, we review the history and examination to assess whether other causes of back pain may be involved, and obtain an MRI of the LS spine. It is important for the clinician to discuss any planned imaging studies with their local radiologists and determine together what approach is most appropriate in their setting. Most radiology departments have established protocols for imaging adults with disc disease but may not have appropriate protocols for children with spondylolysis. It is reasonable to refer a patient with recurrent back pain despite appropriate treatment to a spine surgeon at this point.

Surveillance imaging — Once treatment is completed, some authors advocate obtaining serial radiographs of patients with spondylolysis or spondylolisthesis to observe for new or worsening slippage of vertebral bodies [37]. Serial imaging makes some sense given that a patient’s symptoms may not correlate with the degree of slippage that occurs. However, given the radiation exposure involved, this approach is controversial, particularly in younger patients. In addition, the yield of such aggressive surveillance is low, given that the risk of spondylolisthesis progressing after puberty approaches zero [21,22,37].

We suggest not performing surveillance imaging for patients treated for spondylolysis unless there is some significant change in the patient’s status (eg, pain returns after having completely resolved, neurologic deficits manifest). For patients with Grade I spondylolisthesis, we suggest that standard PA and lateral radiographs of the lumbar spine be obtained yearly during the period of most rapid growth (correlates with Tanner 3 development stage). We do not perform routine radiographs in older adolescents or adults.

In order to decrease radiation exposure in young patients, some medical centers have modified imaging protocols and reduced radiation doses. Exposure from modified low-dose CT has been reduced to a level equivalent to plain radiographs of the LS spine at some centers [38]. It is worthwhile for clinicians to learn about the radiographic protocols available at their hospital and to reduce radiation exposure whenever possible. (See "Radiation-related risks of imaging", section on 'Children and adolescents'.)

PATIENTS WITH PERSISTENT PAIN DESPITE 90-DAYS REST — Patients with pain after 90 days of relative rest may have a greater chance of other pathology causing their symptoms. The clinician should review the patient’s history, examination, and available imaging studies, and carefully consider whether a condition other than spondylolysis or spondylolisthesis accounts for their symptoms. (See "Spondylolysis and spondylolisthesis in child and adolescent athletes: Clinical presentation, imaging, and diagnosis", section on 'Differential diagnosis'.)

If a patient diagnosed with spondylolysis, either clinically or by plain radiograph, continues to have pain despite being compliant with treatment including 90 days of relative rest, or the patient develops radicular pain, neurologic signs, or other concerning symptoms during this period, we obtain a magnetic resonance imaging (MRI) study to determine the source of pain and guide further management. Significant neurologic deficits (eg, focal weakness) indicate the need for immediate surgical consultation. If the patient has imaging studies that identify or suggest an alternative diagnosis, appropriate management follows. If an MRI does not reveal the source of pain, a SPECT CT scan may be useful.

However, if on MRI the patient appears to have pain related to ongoing spondylolysis or Grade I spondylolisthesis, reassessment by a knowledgeable physical therapist and the introduction of a modified rehabilitation program is in order. Consultation with a spine surgeon experienced in the management of spondylolysis and spondylolisthesis at this point is reasonable. Our general approach in this circumstance is to counsel patience and recommend another 90-day period of relative rest, with modified rehabilitation exercises introduced as tolerated. The clinician should continue to monitor the patient closely (every few weeks) to determine when to initiate a return to sport.

If a compliant patient experiences periodic pain with sports activity that does not persist, an assessment of the patient’s biomechanics during sport should be performed. Often, activity must be modified in a manner that reduces stress on the lumbar spine. Examples include tennis players who must change the positioning of their spine and stance to make services less stressful and dancers who must reduce pelvic tilt when performing particular movements. These more complicated cases often require longer periods (eg, 6 to 12 months) before the athlete can return to full sport. Patience is required, but most athletes ultimately can return to full activity.

If the patient has radiographic evidence of spondylolysis and has been evaluated by a surgeon and deemed nonsurgical, we offer them a soft brace. We have the patient wear the soft brace for 30 to 60 days during activity only. We follow these patients monthly to monitor their symptoms and progress with physical therapy, including assessments of core strength.

If pain persists for over 6 to 12 months despite careful reassessment and close compliance with a properly designed rehabilitation program, we refer the patient to a spine surgeon with experience managing spondylolysis and spondylolisthesis.

PROGNOSIS AND COMPLICATIONS — A number of studies have followed patients with spondylolysis and spondylolisthesis over many years and the large majority of patients recover completely [4,7,20,21,39-41]. One such study followed a group of first-graders for 45 years and reported consistently excellent outcomes among patients with either condition regardless of the treatment provided [20].

Short-term results for these patients are also generally favorable. A meta-analysis of 15 observational studies involving 665 patients found that 84 percent of patients with spondylolysis or low grade spondylolisthesis had a successful outcome when treated nonoperatively [4]. A review of five observational studies reported that 80 to 100 percent of pediatric athletes with isthmic spondylolysis returned to full activity in 5 to 12 months [15]. Nevertheless, a substantial minority of patients who return to activity continue to have some degree of back pain [42,43]. (See 'Return to play' above.)

Elite level athletes may have greater motivation to pursue rehabilitation and even in high risk sports such athletes generally return to sport quickly and have excellent overall results. As an example, one observational study followed junior elite hockey players for nine years and found that 96 percent of those with spondylolysis returned to elite level play and returned to any play at an average of eight weeks [44].

It is difficult to estimate the number of "refractures," as many clinicians no longer perform routine imaging as part of the long-term follow-up for patients who are asymptomatic and bony healing does not occur in many cases that are fully healed based on clinical parameters (eg, absence of pain, full activity) [1,4,43].

The prognosis of patients with spondylolisthesis appears to depend on the extent of slippage and severity of symptoms. A retrospective study of patients with high-grade spondylolisthesis followed by orthopedic surgeons reported no significant problems among patients with minimal or no symptoms managed with a period of “watchful waiting” [45]. However, regardless of treatment, patients with a greater slip (Grade III or higher) tended to have a poorer prognosis. Patients who had a delayed surgical intervention did not experience worse long-term outcomes compared with those treated with early surgery. A study of 35 patients with high-grade isthmic spondylolisthesis treated with arthrodesis and reassessed after 29 years reported good outcomes in quality-of-life scores and ability to work [46]. If a patient reaches adulthood without complication, the rate of further slippage drops to almost zero.

The rates of return to sport following surgery for spondylolisthesis vary widely in the literature, which consists primarily of individual case reports with little long-term follow-up. Although military personnel face somewhat different demands than athletes, studies of military personnel with spondylolisthesis offer some insights into prognosis. In a nonrandomized consecutive series of 30 patients who underwent lumbar fusion for spondylolisthesis, 19 returned to full military duty [47]. Further studies are needed to clarify the prognosis of athletes with spondylolisthesis who are managed surgically, particularly those involved in higher risk sports.

The classic operation for patients with high-grade spondylolisthesis is bilateral posterolateral fusion [39,48,49], but advances in direct repair using a number of alternative techniques appear to yield similar results [39,48,50-52]. The main short-term complications of surgery for spondylolisthesis include lack of pain relief and failure to stop slippage [53]. Long-term complications include central canal stenosis and degeneration of the disc above the level of fusion but such events are rare [54,55].

PREVENTION — Studies of patient demographics describe the overall risk for a population but do not predict an individual’s risk for developing spondylolysis or spondylolisthesis. There is little published evidence about the prevention of these conditions.

There are no studies that suggest the use of braces or particular exercises reduces the risk for developing spondylolisthesis or spondylolysis in children or adolescents participating in high-risk activities. One observational study followed 1384 participants over three years and determined that higher serum vitamin D levels did not prevent the development of lumbar spondylolysis [56].

Despite the dearth of high-quality evidence, coaches who are knowledgeable about the risk of spondylolysis and spondylolisthesis can make adjustments for young athletes with low back pain that may reduce the risk of an injury becoming more severe. Anecdotal evidence from coaches suggests that changes in training may reduce the number of young athletes who are unable to participate due to spine injury. As an example, gymnastic programs that intervene early when athletes experience even mild low back pain and adjust training to eliminate techniques involving back extension (eg, back flips, back walkovers, back handsprings) for four to six weeks report a reduction in clinically diagnosed spondylolysis. Similarly, tennis coaches who have their players switch to a slice serve or flat serve motion for both serves and overhead shots (encouraging players to take high lobs after the first bounce) at the onset of low back pain see less time lost to injury among their players.

We use such a common-sense approach when counseling young athletes and their parents. When considering spondylolysis and spondylolisthesis in older children and adolescents, we believe it is best to keep a long-term perspective (ie, overall health and longevity of the young athlete) and to avoid focusing too much on short-term goals (eg, winning the next youth competition). Patience is paramount. Early rest and appropriate use of strengthening exercises as soon as symptoms arise followed by a return to modified activity is a far better approach than trying to “work through” the pain and continue playing, only to develop a more serious injury. The trend towards early specialization in sport contributes to the problem, and we counsel children and adolescents (and their parents) that they should participate in a wide range of sports and activities [57,58].

While high-quality trials of preventive measures are lacking, several additional common-sense measures that may reduce the risk for developing spondylolysis can be taken by coaches and trainers. Such interventions include exercises to improve overall core and abdominal strength (eg, plank variations (picture 3 and picture 8)); back extension exercises (eg, bridge variations (picture 9), deadlifts with proper technique—avoiding any lumbar hyperextension (picture 15 and picture 16)); and exercises to develop symmetric strength of the hip musculature (eg, lunge variations (movie 2); barbell back squats with proper technique and depth—neutral lumbar spine; depth below parallel (picture 17)). We believe it is important for athletes to maintain such a basic strength program throughout their careers. Functional training involving dynamic exercises that emphasize core strength and proper biomechanics for the specific sport played by the athlete are another important component of prevention.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Spondylolysis and spondylolisthesis".)

SUMMARY AND RECOMMENDATIONS

●Definitions and evaluation – Among child and adolescent athletes, spondylolysis typically represents a fracture of the posterior arch in the lower lumbar spine due to overuse and is a relatively common cause of low back pain. Spondylolisthesis involves anterior displacement of a vertebral body due to bilateral defects of the posterior arch and is less common than spondylolysis. The clinical presentation and diagnosis of these conditions are discussed separately. A flow chart that outlines the evaluation and management of patients with suspected spondylolysis is provided (algorithm 1). (See "Spondylolysis and spondylolisthesis in child and adolescent athletes: Clinical presentation, imaging, and diagnosis".)

●Signs associated with dangerous causes of low back pain – Younger children typically do not develop spondylolysis or spondylolisthesis; those with a potentially dangerous cause of low back pain must be evaluated carefully. Symptoms and signs associated with dangerous causes of back pain include: age less than four years; fever; weight loss; severe, constant, or steadily worsening pain; nocturnal pain; history of trauma, malignancy, or tuberculosis; signs of neurologic dysfunction. (See "Back pain in children and adolescents: Evaluation".)

●Initial management – Patients suspected of having spondylolysis but who are free of symptoms or signs suggesting other high-risk conditions or radiculopathy, are observed for two to four weeks and instructed to refrain from inciting activity. Patients whose symptoms resolve often have nonspecific muscular back pain and may resume activity. If pain recurs, these patients are reassessed. (See 'Initial management when spondylolysis is suspected' above.)

●Subsequent management – For patients whose symptoms persist following the initial two to four weeks of rest, we perform a careful evaluation that includes AP and standing lateral plain radiographs of the lumbosacral (LS) spine (no oblique or thoracic views), a screen for hypermobility syndromes, and a focused assessment of muscle strength and flexibility (algorithm 1). The large majority of children who develop spondylolysis or spondylolisthesis do well with simple rest and symptom management, and thus it is usually best to avoid aggressive interventions. Relative rest is often the most effective treatment; we suggest 90 days in most cases. Bracing is not part of our standard treatment but may have a role with some patients. (See 'Overview and principles of management' above and 'First follow-up visit for patients with persistent pain' above and 'Treatment by radiograph findings and patient willingness to rest' above and 'Bracing' above.)

•If the LS radiographs show spondylolisthesis beyond Grade I, we refer the patient to a spine surgeon with experience managing spondylolisthesis; if the LS radiographs reveal other pathology (eg, bone tumor), we refer as appropriate.

•If the LS radiographs show spondylolysis or Grade I spondylolisthesis, we recommend a 90-day period of relative rest with monthly follow-up. Intense activity is not permitted, but daily activities and many cardiovascular and training exercises are allowed provided the patient remains pain-free throughout and following the activity. (See 'Treatment by radiograph findings and patient willingness to rest' above.)

•If the LS radiographs are negative, we give the patient and family a choice but recommend a 90-day trial of relative rest with monthly follow-up. Low-risk sport activity that does not place undue stress on the lumbar spine or involve lumbar extension can continue as long as the athlete does not see an increase in pain with the sport or increasing delayed-onset pain in the 24 to 48 hours post activity.

•Despite our clear recommendations, some patients and their families wish to continue playing their sport and prefer not to observe a period of rest. In these cases, we believe it is important to obtain advanced imaging, usually with magnetic resonance imaging (MRI), to establish a definitive diagnosis and avoid potential complications from other conditions.

●Indications for spine surgery referral – If at any point during management, a patient with spondylolysis or spondylolisthesis begins to manifest signs of neurologic injury, including lumbosacral radiculopathy or any other abnormal neurologic findings, immediate consultation with a spine surgeon is required. The general indications for referral are described separately. (See "Spondylolysis and spondylolisthesis in child and adolescent athletes: Clinical presentation, imaging, and diagnosis", section on 'Indications for surgical referral'.)

●Treatment of symptoms – Symptom control for patients with spondylolysis or low grade spondylolisthesis include position and stretching exercises (picture 6 and picture 7), icing, warm baths or showers (if these provide relief), over-the-counter analgesics (eg, acetaminophen), and topical capsaicin. (See 'Symptom control and basic treatment' above.)

●Follow-up – We follow patients every 20 to 30 days during the period of relative rest. While timing varies, patients who are symptom-free and manifest no tenderness or pain with provocative maneuvers (eg, lumbar extension tests) or basic physical activities (eg, jogging) begin a graduated program that will return them to sport. Typically, we do not perform additional surveillance imaging. For patients with persistent pain despite appropriate treatment or who develop radicular pain, neurologic signs, or other concerning symptoms, we obtain an MRI. (See 'Follow-up' above and 'Patients with persistent pain despite 90-days rest' above.)

●Return to play – The time required for a full return to sport varies depending upon the patient’s physical development (more time is needed if the patient has not begun their adolescent growth spurt), severity of symptoms, compliance with rehabilitation, chosen sport (more time is needed for high risk sports involving repeated lumbar extension), and other factors (eg, presence of hypermobility syndrome). Before permitting a return to full play, we require that the athlete demonstrate sufficient core strength to stabilize their lower back and torso. (See 'Return to play' above.)